AUTHORIZATION TO RELEASE INFORMATION
Student's Name
*
First Name
Last Name
Student's Email
*
example@example.com
Not Authorized:
I do NOT consent to the release of Financial, Academics, Attendance or Health Information.
Contact 1:
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
I consent to the release of all Information regarding Tuition Payments.
*
Yes
No
I consent to the release of all information regarding Attendance.
*
Yes
No
I consent to the release of all Information regarding Academics.
*
Yes
No
I consent to the release of Health Emergency Information.
*
Yes
No
Contact 2:
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
I consent to the release of all Information regarding Tuition Payments.
*
Yes
No
I consent to the release of all information regarding Attendance.
*
Yes
No
I consent to the release of all Information regarding Academics.
*
Yes
No
I consent to the release of Health Emergency Information.
*
Yes
No
Contact 3:
Optional
Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
I consent to the release of all Information regarding Tuition Payments.
Yes
No
I consent to the release of all information regarding Attendance.
Yes
No
I consent to the release of all Information regarding Academics.
Yes
No
I consent to the release of Health Emergency Information.
Yes
No
Signature
*
Date
*
-
Month
-
Day
Year
Submit
Submit
Should be Empty: