Student Fee Disclosure Form
Please complete one form per student. Forms must be submitted to Ignite Entrepreneurship Academy and approved prior to the first date of service. Failure to do so may result in non-payment.
Please specify the type of form: *
Business/Organization Name *
Your answer
First and Last Name of Individual Completing Form *
Your answer
Role of Individual Completing Form *
Your answer
Student First Name *
Your answer
Student Last Name *
Your answer
Course/Activity Enrolled in: *
Your answer
Individual(s) providing instruction to student who must have background check on file: *
Your answer
Instructor Email *
Your answer
Instructor Phone *
Your answer
Billing Address *
Your answer
Address Where Student Will Receive Instruction *
Your answer
Enrollment Start Date *
MM
/
DD
/
YYYY
Expected Enrollment End Date *
MM
/
DD
/
YYYY
Total Cost for Enrollment Period *
Your answer
Approval and Acceptance of Student Fee Disclosure
Once this form is submitted for IEA students enrolling in this activity/course, IEA will send you a list of approved enrollments for your program. If you have any questions, please feel free to reach out to Lani Murray, Distance Learning Director, at lmurray@igniteutah.org.
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