Site Rep Form

By completing and signing this form I confirm my participation in the UConn Early College Experience Program, certify that all personal information provided is accurate and will be used to create and/or maintain my University records, and consent to comply with the policies and procedures of the University of Connecticut.

I understand I am serving as the primary contact for UConn ECE information at my high school. As a liaison between UConn and my school, I am familiar with UConn ECE policies and procedures. I will provide reliable program information for interested students, parents, and instructors; manage student registration; be familiar with the billing process and course evaluation procedures; and assist with the UConn ECE class roster verification process.

I understand that my UConn ECE students’ educational records are to be kept confidential under FERPA (Family Educational Rights and Privacy Act), and will be disclosed only with their consent, as the student of record or otherwise in accordance with the University’s FERPA Policy. As a UConn ECE Site Representative, I understand that I must obtain written consent from a student prior to communicating student registration and grade information with a third party, such as a parent or guardian.

Once this form is submitted we will contact you for your social security number so a University account can be created or reactivated for you. Access can then be granted to UConn’s Library resources, e-learning system (HuskyCT), and the Student Administration System where you will have access to view course and student information specific to your high school. Providing your social security number is voluntary; it is not required. If you choose not to provide your social security number, you must disclose if you have previously been affiliated with the University.

Site Representative Form

Are you a:*
- New Site Rep
- Current Site Rep (updating information)
School Information
High School Name*
High School Address*
Street Address Address Line 2 City State ZIP Code
High School Phone Number*
Phone extension
High School Fax Number
High School Email Address*
Personal Information
Prefix*
- Dr.
- Mr.
- Mrs.
- Ms.
First Name*
Middle Name*

This information is used to search the University system to connect any past records that you may have. If not applicable, please indicate "N/A"
Last Name*
Suffix
Maiden or Previous Name*

This information is used to search the University system to connect any past records that you may have. If not applicable, please indicate "N/A"
Date of Birth*
MM slash DD slash YYYY
Position/ Title
Personal Home Address*
Street Address Address Line 2 City State ZIP Code
Personal Phone number
Personal Email Address (optional)
T-shirt size (unisex sizing)
I understand that I will be contacted to provide my social security number.*
- Acknowledge
We request social security numbers so that our Site Representatives can gain access to the UConn Libraries’ online research materials and e-delivery system and UConn e-learning system, HuskyCT. Providing your social security number is voluntary; it is not required. If you choose not to provide your social security number, you will have access to the Student Administration System (SAS) to view your school’s class rosters, but due to system requirements, you will not have access to the library and/or HuskyCT systems. *The University requests that you provide your Social Security Number (SSN). We are required by federal law to inform you of this request. The SSN is collected to enable the University to comply with federal requirements mandated under IRS tax laws and the Title IV student aid legislation and for other administrative purposes. The University assigns each site representative a unique identifier that is not the SSN that is used for most administrative purposes.
Site Rep /S/ Signature
Untitled
Name
This field is for validation purposes and should be left unchanged.

UConn Early College Experience

Site Rep Form

Site Representative Form

School Information

Personal Information

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