Center for Academic Assistance (CAA)

Academic Retention Program
 Confidentiality Statement

Please select with whom you will allow CAA to share your information. 

COMPLETE each box (type your name for student signature, fill in the date). SAVE and PRINT this form for your records. (Save Directions: Click File, click Save As. In the Save Web Page dialog box, click the Save in down arrow and select where you want to save this form, click File name and rename the form if you want, click Save as type and select Text File.) (Print Directions: Click File, click Print, click OK). Email it as an attachment jdomino@fgcu.edu. 

I  permit Center for Academic Assistance (CAA) to release my academic retention folder to: (please check all that apply)

I refuse to release confidential information

Academic advisor, Parents

FGCU Counseling Center ,  FGCU Financial Aid

FGCU Office of Multiple Access Services (OMAS)

Testing Services ,  Career Development

Advising ,  Registration

Other

I have read the Academic Probation pages in the FGCU catalog. 

Last Name, First Name

Social Security Number        (###-##-####)

Student Signature: , Date:

CAA Signature: , Date:

If CAA discloses student information, copies will be provided to the appropriate checked/listed parties.