AUTHORIZATION to RELEASE or WITHHOLD INFORMATION
Please return your completed form to the Admissions and Records Office
(Huntsville or Decatur) or via email at admissions@calhoun.edu
*NOTE* A scanned picture ID must accompany your request. (Driver’s License, Passport, Official Government ID)
This form serves as student consent for records to be released to Parent(s), Legal Guardian(s), other tuition providers or other
indicated individuals. This form may also be used to opt out of directory information disclosure. Exceptions may include those with
a legitimate educational interest, such as financial aid, Board of Trustees, auditors, and the court system.
Student’s Name: ______________________________________________________ _ Student ID#: ______________________________
PLEASE READ:
In accordance with the Family Educational Rights and Privacy Act of 1974 (FERPA), the undersigned student hereby permits Calhoun
Community College to disclose the information specified below to the following individual(s) or agency(ies):
Name: ________________________________________________Relationship: _______________________________________________
Name: ________________________________________________Relationship: _______________________________________________
Name: ________________________________________________Relationship: _______________________________________________
Name: ________________________________________________Relationship: _______________________________________________
This consent shall be valid throughout the student’s enrollment at Calhoun Community College and thereafter, but may be modified or
rescinded by the student. The recipient of the student’s information (as named on lines above) agree that they shall not disclose the specified
information to third parties without the express consent/authorization of the student.
INFORMATION TO BE RELEASED:
The following information from my records at Calhoun Community College may be disclosed to the above specified person(s):
Schedules, Grades and Academic Standing
Disciplinary Records
Tuition and Fee Statements
Financial Aid Information
All records or information pertaining to student
Other, please specify ( ________________________________________________________________________________________ )
Please do not release my directory information to anyone other than those defined
as having a legitimate educational interest*
I have read and understand the contents of this consent form pertaining to
the Family Educational Rights and Privacy Act of 1974.
Student’s Signature: ________________________________________
Date: ________________________________________
Rev 11/19
For Admissions Office Use Only
Processed by: __________________
Process Date: __________________
* Directory Information includes: name, address, telephone listing, email address, date/place of birth, major field of study,
dates of attendance, enrollment status, class standing, degrees, honors, awards, most recent educational agency or institution attended.
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