Fillable AUTHORIZATION FOR RELEASE OF INFORMATION (Cochise College)

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AUTHORIZATION FOR RELEASE OF INFORMATION (Cochise College)

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___________________________________________________ ___________________________________
Admissions and Registration
901 N Colombo Ave
Sierra Vista, AZ 85635-2317
Phone: 800-593-9567
AUTHORIZATION FOR RELEASE OF INFORMATION
STUDENT INFORMATION
Student ID #:
Phone:
Last Name:
First:
M.I.:
THIRD-PARTY DESIGNEE INFORMATION (Individual or Agency to whom access is granted)
Agency:
Last Name:
First:
Relationship:
Address:
City:
State:
ZIP:
Last Name:
First:
Relationship:
Address:
City:
State:
ZIP:
LENGTH OF RELEASE
One time use: This authorization can be used only once.
One semester: This authorization will remain in effect through __________Term ________Year.
One year: This authorization will remain in effect unless I withdraw this authorization or for a maximum of one year.
PURPOSE FOR THE AUTHORIZATION FOR RELEASE OF INFORMATION:
Admissions & Records – Admissions application, grades, registration & schedule information, residency information,
transcripts, student ID, and related information
Financial Aid – Financial Aid application documents, status, satisfactory academic progress, awards and related
information.
Student Finance – Student account invoices, statements, payments, charges, credits, tax forms (including 1098T),
and related information.
Counseling, Academic Advising, Testing & Disability Support Services
Faculty – Letters of recommendation, grades, attendance, and related information
No limitation – share anything and everything
Other _______________________________________________________________________________
I understand that my records are protected under the Family Educational Rights and Privacy Act of 1974 and cannot be
released without my written consent. I hereby waive all provisions of the law and privilege relating to the records
described in this disclosure. I certify that this consent has been given freely and voluntarily. I may revoke this consent at
any time by providing written notice to the Admissions and Registration office.
This form must be presented along with government issued photo ID and signed by the student in front of an
authorized Cochise College employee.
Signature Date
Revised 11/16
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AUTHORIZATION FOR RELEASE OF INFORMATION (Cochise College)

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Completed 25 July 2020

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