SITI Confidentiality Statement

Center for Education Placements and Partnerships

Please fill out this confidentiality form as a reminder not to disclose any CONFIDENTIAL student data while you are completing your online practicum experience.

If you see this don't fill out this input box.

Today's Date:

Full Name:

KSU #:

Address 1:

Address 2:

City / Sate / Zip Code:

Email Address:

Phone Number:

Recognition Statement #1

I have read, understand, and agree to Recognition Statement #1, which states the following:

I understand that I do NOT have a GaPSC Professional Certificate, and therefore, I am not eligible for certification in Instructional Technology offered by the GaPSC.

Recognition Statement #2

I have read, understand, and agree to Recognition Statement #2, which states the following:

I understand that I am not eligible for an upgrade to my teaching certificate from the GaPSC, since I do not have a GaPSC Professional certificate.

Recognition Statement #3:

I have read, understand, and agree to Recognition Statement #3, which states the following:

I understand that the degree in Instructional Technology may not lead to a pay increase from my school or district since I do not have a GaPSC Professional certificate.

Recognition Statement #4:

I understand that if I were to attain a GaPSC Professional certificate in the future, that I may still not be eligible for certification in Instructional Technology since I did not have a GaPSC Professional certificate at the time I enrolled in the Instructional Technology degree program at KSU.

Electronic Signature:

Entering my first name, middle initial, and last name in the box above indicates my electronic signature on this form.

By submitting your information, you consent to KSU using the information to contact you via phone, text message, or email for informational and promotional purposes. more To learn more about how KSU collects and processes personal data, read our Privacy and Legal Notice.