Student Fee Disclosure Form

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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: *

This is a new student fee disclosure form.

This is a student fee change form for an existing student with a form already submitted.

Business/Organization Name *

First and Last Name of Individual Completing Form *

Role of Individual Completing Form *

Student First Name *

Student Last Name *

Course/Activity Enrolled in: *

Individual(s) providing instruction to student who must have background check on file: *

Instructor Email *

Instructor Phone *

Billing Address *

Address Where Student Will Receive Instruction *

Enrollment Start Date *

YYYY

Expected Enrollment End Date *

YYYY

Total Cost for Enrollment Period *

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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