MCBIA Apprenticeship Student | Marion County Builders Association

Apprentice Full Name *

First

Middle

Last

Sponsoring Company Name (if applicable)

Apprentice Address *

Address Line 1

Address Line 2

City

State

Zip Code

Apprentice Email *

Apprentice Date of Birth *

Apprentice Social Security Number

(Only used for training record identification)

Apprentice Signature *

I, the above named APPRENTICE, with full knowledge of the provisions and my rights thereunder, do hereby expressly waive my rights under 20 USCA S1232g(b) which provides that a student's permission (or the permission of his/her guardian, if the student is under 18 years of age) is necessary before an educational agency or institution may disclose the student's education records to any source outside the school system. Permission to disclose my records (or my child's records) is specifically restricted to the disclosure of grades and attendance records to the Registration Agency for the purpose of evaluating my progress as an apprentice and further administering of the Florida Apprenticeship Program provided for under Chapter 446, Florida Statutes.

Signature Date *

Parent Full Name (if a minor)

Parent Signature (If a minor)

Signature Date

Applicant's Sex *

Male
Female

Ethnic Group (optional)

Hispanic or Latino
Not Hispanic or Latino

Veteran (optional)

Veteran
Non-Veteran

Disability

Yes
No