Lakeland Students Help

Last Name *

First Name *

Middle Initial

Birth Date (e.g. 04/15/2001) *

Street Address- (Include Apt no if applicable) *

City *

ZIP *

Phone Number *

Email Address *

College you are attending or planning to attend *

Year (FR/SO/JR/SR/Grade) *

MAJOR *

Gender *

Male

Female

Status *

Fulltime Student

Part time Student

Marital Status

Do you have children to support? *

Yes

No

Have you used LEAF Services before? *

Yes

No

Would you like to receive email notifications from LEAF? *

Yes

No

Permission for Information Release

The principal purpose for requesting the information on this form is to track student attendance, retention, and graduation information of Lake and Geauga County students at postsecondary institutions. Information is reported only as collective data; no identifying personal information will be published. LEAF is granted the authority to request this information under the Family Educational Rights and Privacy Act (FERPA) Subpart D Section 99.31 Paragraph (6)(i)(B) and Paragraph (6)(ii)(A) and (B).

Individuals have the right to review their own records in accordance with LEAF’s personnel policy. Information on applicable policies and agreements can be obtained from the Executive Director.

Please sign the following: I give my permission to the Lake/Geauga Educational Assistance Foundation to use my information in the therefore described research study.

Student Signature *

Date *

Parent Signature

Date

lake/geauga educational
assistance foundation

Lakeland Student Help Open Hours

Monday’s 11 a.m. to 1:00 p.m.

Student Information

Permission for Information Release

Lake/Geauga Educational Assistance Foundation

lake/geauga educational assistance foundation

Lakeland Student Help Open Hours

Monday’s 11 a.m. to 1:00 p.m.

Student Information

Permission for Information Release

lake/geauga educational
assistance foundation