Student Health and Counseling Bridge Fee Form

Summer SHCC 2024 Bridge Fee Form

PH: 907-474-7043 FX: 888-837-2146
Name*

First NameLast Name
UA Identification #*
Continuation of Services I will be using:*

Medical servicesCounseling services
The SHCC bridge fee allows students not taking classes during the summer semester to have continuation of medical and counseling services until the fall semester begins. I approve of this charge being added to my student account.*

Please charge this $100 fee to my student account
By signing this document, I affirm that the information I have provided on this form is true and that I am in agreement with any additional charges that may be added to my account resulting in the above selection. I understand that if I default on this student account, I am responsible for the coullection, attorney and legal fees, which may be base on a percentage at a manximum of 40% of the debt, necessary for the collection of any amounts owed to the University of Alaska. The University of Alaska may garnish my Alaska Permanent Fund Dividend under Alaska Statues 14.40.251 amd 43.23.073. I also understand that the past due debt may be reported to credit bureaus.
This is for Printed form that have been downloaded and printed.

For downloadable form, please use this signature line

Signature:___________________________________

Date: __________________
Date of Signature*

MonthDayYear
Date
Signature

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UAF is an affirmative action/equal opportunity employer, educational institution and provider and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination/.
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Summer SHCC 2024 Bridge Fee Form