Checking this box indicates that I have read and understand the terms of the Genesee Opportunity stipend, and the information I have provided above concerning residency and enrollment in a Genesee County high school is true to the best of my knowledge.

By checking this box, I hereby authorize my high school and college or training institution, through its agents and employees, to release any financial aid, demographic, or academic information to the Genesee Intermediate School District to facilitate their analysis of my stipend eligibility and the educational and economic impact of this stipend on Genesee County. This release is authorized for the duration of the time that I receive the stipend funds. In order to rescind this authorization, I acknowledge that I must submit written notification of rescission to the Office of the Registrar of my school or training institution of choice. This rescission would result in the termination of the stipend.

I also give permission to Genesee Opportunity to use information regarding my stipend in promotion of Genesee Opportunity. Checking this box indicates that I have read this Authorization to Release Educational Records and that I authorize the release of records as described above. Checking this box also indicates that I have read and agree to adhere to the stipend conditions as set forth in this document. I understand that failure to adhere to these requirements may result in termination of this stipend.

By checking this box, I agree to receive text messages regarding my Genesee Opportunity application.

By typing my full name in the box below, I authorize release of records and I agree to adhere to the stipend conditions as set forth above.