Kean ID1800 Holocaust, Genocide and Modern Humanity
Off-Site Course High School Participant Eligibility Form
To process registration for ID1800, both pages of this form need to be completed along with the Kean Off Campus Registration Form.
Student Certification-Parental Consent for
Last Name ______
First Name ______ Middle Name ______
Social Security # (required) ______Date of Birth______
High School______Graduation Year ______
Certification Statement To be completed by student
I hereby certify that the program registration information provided is accurate and complete. I understand that my complete registration form plus tuition payment permits Kean University to process my enrollment into ID 1800. I understand that any misrepresentation or omission of fact will constitute cause for nullification of my participation in (or dismissal from) the ID1800 program.
Print Name ______Signature______Date______
School Enrollment Certification To be completed by school counselor or principal
I certify that the above-named student is a currently enrolled student in good academic standing at and meets the established criteria to participate in ID1800.
Name ______Title______
Signature______Date______School Seal
High School______Graduation Year ______
School Address ______
City ______State ______Zip Code ______
School Counselor/Principal ______
School Phone ______School Fax ______
Authorization for Photos
_____ I hereby give permission to Kean University to photograph and/or videotape my son/daughter at events held on the Kean University campus, during classes and/or field trips. I grant permission for any photographs to be published on the Kean website and/or any newsletter regarding the program. Any photographs may be utilized by Kean University, in any legitimate non-profit manner without limitation or reservation.
_____ I do not grant permission to Kean University to take photographs and/or videotape of my son/daughter.
Parent/Legal Guardian Name ______Signature______Date______
Acknowledgement of Tuition Costs
I hereby acknowledge that by registering my child for this course, I am obligated to remit tuition payment to Kean University in a timely manner upon receipt of a bill. This payment will allow my child to earn 3 University credits and receive a transcript indicating such. These credits may be used at Kean University in the future or transferred to all NJ State institution and most all other Middle States Accredited institutions.
Parent/Legal Guardian Name ______Signature______Date______
Parent/Guardian, Emergency Contact and Health Information (To be completed by parent/legal guardian)
Parent/Guardian Name ______
Home Address ______
City ______State ______Zip Code ______
Home Phone ______Cell Phone ______Other phone ______
In case of an emergency, how should you be contacted?
In case you are not immediately available, who should be contacted?
Name ______Relationship ______
Home Address ______
City ______State ______Zip Code ______
Home Phone ______Cell Phone ______Other phone ______
Complete and return Participant Eligibility Registration form along Kean Off Campus Registration Form to the coordinator of the program at your child’s school.