BreakThru Student Confidentiality Form

As part of my participation in the Georgia STEM Accessibility Alliance (GSAA) Virtual Mentoring Program, I, a student in the program, hereby enter into this Agreement with BreakThru staff and mentors. All information received by me pertaining to BreakThru, mentors or other students business is presumed to be confidential until it becomes readily available to the general public lawfully and without breach of confidential obligation.

1. Student Name *This question is required.

2. Name of Parent/Guardian if under 18

3. Date *This question is required.

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I understand that submission of this form constitutes a digital signature, and I hereby acknowledge that I have read this Agreement and agree to it's terms.