Academy Agreement
This agreement is made and entered into this _____ (day) of__________ (month), 20____ (year), by and between
_____________________________ (student name), and the Kirkwood Regional Center at the University of Iowa.
I, _______________________________ (student name) agree to abide by the following terms:
1. I understand that by participating in a career academy at the Kirkwood Regional Center, I am making a yearlong commitment, and that my registration will be processed and schedule changes prohibited unless Kirkwood
Regional staff are notified by my high school district staff of schedule changes prior to the May 15th deadline
(see College Credit in High School Student Commitment, pg. 2).
2. I have received, read, and fully understand the special requirements for being a student at the Kirkwood
Regional Center, including the attendance policy, its academic, conduct and calendar requirements (see
Concurrent Credit in High School Student Conduct Agreement, pg. 2). _______ (student initials)
3. I understand that if I may be asked to leave the program if I disrupt the learning environment or establish a
pattern of ignoring school rules (see Concurrent Credit in High School Student Conduct Agreement, pg. 2).
_______ (student initials)
4. I have received, read, and fully understand the procedures and guidelines summary for responsible use of
Information Technology at Kirkwood Community College (see Procedure and Guidelines Summary for the
Responsible Use of Information Technology, pg. 3), as well as the guidelines listed below. _______ (student initials)
a. NO Instant Messaging (Yahoo, AOL, MSN, etc)
b. NO computers in class unless Instructor gives permission
c. Research, Facebook, and Internet browsing in NOT permitted during class unless Instructor gives
permission
d. Kirkwood laptops must be signed out and signed in when used
e. Kirkwood laptops do not leave the Regional Center
5. I have received, read and fully understand Kirkwood Community College’s attendance policy and inclement
weather and delay policies (see Class Attendance Policy, pg. 5 and Regional Center Inclement Weather
Cancellation and Delay Polices, pg. 5). _______ (student initials)
6. I have received, read, and fully understand that Kirkwood Community College and its designees, agents, and
applicable media vendors will have access to media forms that include my name or likeness see Kirkwood
Authorization and Release Form, pg. 6). _______ (student initials)
7. To adhere to all Regional Center policies and regulations. (see Concurrent Credit in High School Student Conduct
Agreement, pg. 2). _______ (student initials)
Student Signature_____________________________________________
Date____________________
IF UNDER 18, PARENTAL CONSENT IS REQUIRED
The undersigned hereby has received, read, and fully understand the orientation documents associated with the Regional
Center policies and procedures, including the terms listed in the “Additional Things to Consider” section (see Additional
Things to Consider, pg. 8).
Parent/Guardian Name _________________________________________
Parent/Guardian Signature_______________________________________
Date____________________
Emergency Contact Information
Student Name: ______________________ Student cell phone: ___________________ Birth date:___________
Parent/Guardian # 1 Name: _____________________________________________________________________
Daytime Phone
Alternate Phone
Parent/Guardian # 2 Name: _____________________________________________________________________
Daytime Phone
Alternate Phone
Can we email you Kirkwood’s monthly Parent Newsletter?
If yes, email: ____________________________________________
Authorizations (please check and sign below)
In case of emergency, the school will attempt to contact parent(s)/guardian(s). If medically necessary, the student will be
transported by ambulance to an emergency care facility.
_______YES, I authorize my child be taken to ______________________Hospital in case of medical emergency.
Names(s) of designated adult(s) who will assume responsibility if parent is unavailable:
Name: ______________________________________________________________________________________________
Relationship
Daytime Phone Number
Name: ______________________________________________________________________________________________
Relationship
Daytime Phone Number
_______YES, I authorize the above named student to attend off-campus field trips with the Kirkwood Regional Center
faculty and/or staff. Students who attend field trips must ride provided transportation.
Parent/Guardian signature: ______________________________ Date: ____________
TELL US MORE ABOUT YOURSELF!
I participate in the following extracurricular activities/clubs/groups/sports:____________________________________
__________________________________________________________________________________________________
Favorite snack/treat:_________________________________________________________________________________
Hobbies:___________________________________________________________________________________________
When I do something amazing, I prefer to be recognized:
□ Publicly
□ Privately
□ I prefer not to be recognized
After high school I plan to: ____________________________________________________________________________
__________________________________________________________________________________________________
REGIONAL CENTER STUDENT AMBASSADORS
□ Yes! I am interested in becoming a Student Ambassador.
What do they do?
Student Ambassadors are an essential part of the Regional Center team! Student ambassadors are passionate Kirkwood
students who want to share their own Kirkwood experience with prospective students, parents, and community members
during guided building tours and presentations. They get students excited about beginning their Kirkwood experience, and
share insider tips and tricks on how to be a successful student. Student ambassadors will be called upon to help with group
tours, school presentations, activities and other events on the Regional Center campus.
What’s in it for me?
There are tons of perks! Student Ambassadors network with staff, faculty, new students and parents; plus they get many
leadership opportunities. Being an Ambassador will help your communication skills both personally and professionally.
Above all else, it's a great way to get involved, meet new friends and have fun!
How do I get started?
The first step to becoming a Kirkwood Student Ambassador is to attend our Fall Kick-off Party! This is a
fun informational session for any student who is interested in joining the group.