Information Release Form

Feather River College TRiO SSS Program Information Release Form

Please contact program director, Billy Ogle, at (530)283-0202 ext 221 or wogle@frc.edu with any questions.
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*

MonthDayYear
Date
Gender*

MaleFemale
Marital Status*

SingleMarriedDivorcedSeparatedWidowed
Ethnicity/Race*

American Indian or Alaskan NativeAsianBlack or African-AmericanNative Hawaiian or Other Pacific IslanderWhite/Caucasian
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*
CONFIDENTIALITY AND STUDENT RELEASE OF INFORMATION
SSS handles student information confidentially pertaining to FERPA regulations. Your signature below verifies your full agreement and understanding of this application.*

I authorize SSS to obtain disability data, financial aid documents, transcripts, assessment scores, verify my citizenship status, and review my academic standing in order to ensure that I qualify for SSS services.I give SSS permission to track me using my birthdate and Social Security Number or correspond with me directly for five (5) years after I leave FRC, to assist with required program reporting to the US Department of Education and in the interest of better serving future students.I give SSS and its staff permission to communicate with other colleges and universities as well as my parents(s) or legal guardian with regard to my academic standing & progress, and academic records & transcripts.I give permission for SSS to contact me via email, text message, and phone for the purposes of assisting me academically as well as informing me of SSS programs and events.I certify that the information I have given is correct to the best of my knowledge. I understand that if any of this information is found to be false, my eligibility for SSS services will be jeopardized.
Signature*

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Today's Date*

MonthDayYear
Date
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Feather River College TRiO SSS Program Information Release Form

CONFIDENTIALITY AND STUDENT RELEASE OF INFORMATION