STUDENT AFFAIRS
AUTHORIZATION TO RELEASE
STUDENT INFORMATION
I ______________________________________ (BSU ID#): ___________________hereby authorize Bemidji State University to
release and/or orally discuss the education records described below about me to: (print names of parents,
guardians, individuals or organization)
__________________________________________________ ________________________________________________________
Last Name First Name Last Name First Name
or Organization or Organization
_______________________________________________________ _____________________________________________________________
Relationship to Student Relationship to Student
The specific records covered by this release are (select checkbox(s)):
Student conduct records (including drug and alcohol records)
Advising records
Disabilities Services records
Student billing and financial aid
Grade reports (at end of semester)
Housing (charges, credits, and itemized damage charges)
Immigration status
Application process
Registration (number of credit hours, add/drops)
All of the above
I understand that the student records information listed above includes information which is classified as my
private information under Minn. Stat. § 13.32 and the Federal Family Education Rights and Privacy Act. I
understand that by signing this Informed Consent Form, I am authorizing the University to release to the
persons named above and their representatives information which would otherwise be private and not
accessible to them.
I understand that, at my request, the University must provide me with a copy of any educational records it
releases to the persons named above pursuant to this consent. I understand that I am not legally obligated to
provide this information and that I may revoke this consent at any time. This consent expires after one year
or until I withdraw my consent, whichever comes first. A photocopy of this authorization may be used in the
same manner and with the same effect as the original documents.
I am giving this consent freely and voluntarily and I understand the consequences of my giving this consent.
Student Signature_________________________________________________________ Dated:_________________________________
(Effective for one year after date)
Return to: Records Office - Deputy Hall 101
Bemidji State University, 1500 Birchmont Dr. NE #13, Bemidji, MN 56601-2699
‡ Minnesota State Colleges & Universities ‡
218-755-2075 / Fax: 218-755-3961 / 313 Deputy #20, 1500 Birchmont Drive NE, Bemidji, MN 56601-2699
A member of The Minnesota State Colleges and Universities System Bemidji State University is an equal opportunity educator and employer.
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