Information Release Form

Name

First NameLast Name

FRC ID #

Address

Street Address

Street Address Line 2

CityState

Zip Code

Cell Phone Number

Area CodePhone Number

Personal Email Address

example@example.com

Date of Birth

Date

Gender

Marital Status

Ethnicity/Race

Photo Release – Please initial below to agree to the following:

I hereby grant permission to the Feather River College Student Support Services program to use my photograph on the FRC World Wide Web site or in other official printed publications without further consideration, and I acknowledge the College’s right to crop or treat the photograph at its discretion.
I also acknowledge that the College may choose not to use my photo at this time, but may do so at its own discretion at a later date. I also understand that once my image is posted on FRC’s website, the image can be downloaded by any computer user on or off campus.
Therefore, I agree to indemnify and hold harmless from any claims the following:
- The FRC Board of Trustees, and the California Community College System
- State of California
- All Employees, Feather River Community College District

Please Type Your Initials Here

SSS handles student information confidentially pertaining to FERPA regulations. Your signature below verifies your full agreement and understanding of this application.

Signature

Today's Date

Date

Feather River College TRiO SSS Program Information Release Form

CONFIDENTIALITY AND STUDENT RELEASE OF INFORMATION