NHADA Student Grant - Student Authorization

NHADA Job Training Grant

Student/Employee Authorization
I am attending the following college :

Great Bay Community College (GBCC) - Program Coordinator Paul Giuliano (pgiuliano@ccsnh.edu)Lakes Region Community College (LRCC) - Department Chair Jamie Decato (jdecato@ccsnh.edu)Manchester Community College (MCC) - Department Head Marc Bellerose (mbellerose@ccsnh.edu)Nashua Community College (NCC) - Department Chair Karl Wunderlich (kwunderlich@ccsnh.edu)White Mountain Community College (WMCC) - Department Head Troy Lachance (tlachance@ccsnh.edu)
I am applying for the :

Fall SemesterSpring Semester
I am authorizing CCSNH to discuss and release the following information with my employer listed below and NHADA Education Foundation and its employees.

Academic Records (transcript, grades, GPA)Advising RecordsStudent Account and Billing RecordsFinancial Aid Records ( grants, loans, scholarships)Student Affair Record ( housing, conduct/disciplinary)Other
With my signature, I acknowledge this consent and authorization to be valid. I understand that this consent remains in effect until written revocation from me is received by the above-mentioned off/ department/school. I also understand that such revocation does not affect disclosures previously made.
Student Information
Student Name
Date of Birth

MonthDayYear
Date
Signature

Clear
Phone Number
Please enter a valid phone number.
Email
Student ID number
Address
City
State
Zip
Employer Information
Employer Name
Employer Address
Employer City
Employer State
Employer Zip
Service Manager Email
example@example.com
Service Manager Name
Course Information
Title of College Course(s)
Title of College Course(s) and Semester
CRN Number
Cost of Course
Questions? Please contact us at foundation@nhada.com or 603-224-2369
Should be Empty:

NHADA Job Training Grant

Student Information

Employer Information

Course Information