Checklist for Financial Clearance

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1 Checklist for Financial Clearance Student Name: Student ID# (if known): Housing Yes No Will you be residing in campus housing? Medical/Health Insurance Do you need a Hellenic College sponsored health insurance plan? If yes: Single Plan Married Plan With Children # of Children If covered under a plan, please a copy of your insurance card (front and back) along with Waiver Form. Student ID Card Have you ed a photo for your student ID? to: jking@hchc.edu. If no, please contact the Bursar s office to arrange for photo to be taken Parking Will you be parking a vehicle on campus? If so, how many vehicles? FERPA Form Have you completed and returned your FERPA consent form? Miscellaneous Alternate address: Alternate phone: Alternate

2 HCHC Student Consent for Release of Information For the academic school year 2014/2015 The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. 1232g; 34 CFR Part 99) is a Federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. This act protects your personal information from being distributed to third parties. Therefore Hellenic College and Holy Cross Greek School of Theology must have a signed acknowledgement from you before personal information can be released to a third party (i.e. spouse, parent, employer, etc). For more information about FERPA, please visit: I,, request that information pertaining to my student records be released to the following: Name: Relationship: Address: City/State/Zip: Phone Number(s): Name: Relationship: Address: City/State/Zip: Phone Number(s): I acknowledge by my signature that by giving this consent I am willingly waiving my rights protected by the Family Education Rights and Privacy Act (FERPA). I understand that I will be responsible for any course of action that the above person/s might take pertaining to my student records. I also agree to hold Hellenic College and Holy Cross Greek School of Theology harmless of any damages resulting from the release of this information. Student signature Date ID# (if known)

3 Payment Plan Application I wish to use the Hellenic College Payment Plan for the semester indicated below. By submitting this application, I am indicating that I have read the terms and conditions outlined below and that I understand and agree to abide by the terms and conditions. Semester: Student s Name: Student ID# (if known): Date: Address: City/State/Zip Code: Home Number: Cell Number: Total Net Amount Due: $ 1 st Installment due September 20, 2014 $ ¼ payment 2 nd Installment due October 20, 2014 $ ¼ payment 3 rd Installment due November 20, 2014 $ ¼ payment 4 th Installment due December 20, 2014 $ ¼ payment You can pay by check, money order, or any major credit card. Please make all checks payable to: and send to: Terms and Conditions Bursar 50 Goddard Avenue Brookline, MA There is no application fee or interest charged for this benefit. Financial Aid will be applied to any outstanding balance, including the Payment Plan, before refunds or credits are disbursed. All billed educational costs (tuition, fees, room and board) are allowable budget costs on this plan. The Plan may be cancelled at any time by notifying the bursar in writing and including payment in full. For students withdrawing from school, refunds or monies paid will be handled according to the College s refund policy. Hellenic College reserves the right not to offer the Payment Plan in cases where applicants have not paid according to their payment schedule (e.g. missing 2 payments). Student Name: Borrower s Name: Date: Borrower s Signature: Approved by:

4 Insurance Waiver Dear Students, Massachusetts Law requires that all students enrolled in at least 75 percent of a full-time course load at an institution of higher learning in Massachusetts must either provide proof of enrollment in a medical insurance plan that meets the Commonwealth mandated guidelines or be enrolled in a plan sponsored by (HCHC). If you are a full-time or three-quarter time undergraduate or graduate student at HCHC, you are required to have sufficient health insurance coverage while attending the college. To be eligible to waive out of the college sponsored plan, you must be currently enrolled in a health insurance plan with comparable coverage either as a dependent (on a parent's or spouse's plan) or through a plan you have at your place of employment or have purchased yourself. If you are eligible to waive out of the Hellenic College sponsored plan, please complete the attached form and return electronically by or by mail with a copy of the front and back of the insurance card issued by your current provider. Please return the waiver form and insurance card to the following address or to jking@hchc.edu by Friday, August 1, 2014 Office of the Bursar 50 Goddard Avenue Brookline, MA If you have questions regarding this Insurance Waiver or need any assistance with the Financial Clearance process, please do not hesitate to call my direct line at Thank you, Janice King Office of the Bursar

5 Student Health Insurance Plan Waiver Form To be eligible to waive out of the college sponsored plan, you must be currently enrolled in a health insurance plan with comparable coverage either as a dependent (on a parent's or spouse's plan), or through a plan you have at your place of employment or have purchased yourself. A waiver must be submitted at the beginning of each academic year. The deadline to waive participation in the sponsored plan for the Fall Semester is Friday, August 1, Student Information Name: Student ID No: Date of Birth: Anticipated HCHC Graduation year: Insurance Information Insurance Company Name: Policy No: Name of Policy Holder Relationship to Student: PLEASE READ AND SIGN By signing this waiver I acknowledge that: 1. I am currently covered by the above-mentioned insurance policy and will maintain coverage for the full academic year. 2. I acknowledge that my current policy provides reasonably comprehensive coverage of health services and that these services are reasonable accessible to me while I am attending school. 3. I acknowledge that by submitting this signed waiver form that I assume full responsibility for any medical expenses incurred until August 31, I certify that the above information is true and accurate. Date: Student Signature (Parent s signature if under 18)

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