Internet Access Form 2

State of Hawaii Department of Education

INTERNET ACCESS STUDENT APPLICATION FORM

Name:

School: Name of School

Address

City, State Zip

Phone

Grade: ________ Teacher: _________________________

 Teacher's Signature:

Student's Home Address:

Please read and sign the statement below:

I understand that I will be held accountable for all activities including, but not limited to, the content of materials sent by mail, news, or any other means using my account privileges. I agree to abide by the Department of Education guidelines and that my use of this system will be for educational purposes only. I agree not to hold the State of Hawaii Department of Education, the University of Hawaii, Budget and Finance Information and Communication Services Division or Maui High Performance Computing Center nor any of its employees nor any of the institutions or networks providing access to the Internet responsible for the performance of the system or the content of any material accessed through it.

(Student Signature) (Date)

INSTRUCTIONS: Prepare 2 copies. Retain one copy; forward other copy to sponsoring teacher.