Admissions & Records
College of the Siskiyous, 800 College Ave., Weed, CA 96094
Phone: (530) 938-5500 - Fax: (530) 938-5367 – Email: email@example.com
The Family Educational Rights and Privacy Act of 1974 and the California Education Code (Section 76243) prevent the
release of education records and information without the written consent of the student. In order for you to authorize the
information indicated below, please complete, sign, and date the following form. Original Release will be filed in
Admissions and Records.
1) I, authorize College of the Siskiyous to release/discuss my student records and other
information to the individuals named below. Please give full name of individual(s), who they are in relation to you and a
contact address and phone number.
2) Please select a code word that you will only share with the parties above to use for release of information.
3) I am aware that the Record/Information Release is in effect from the date indicated on this form for the time I am a
student at College of the Siskiyous. Changes to permission for disclosure must be made in writing to the Admissions and
I authorize release of the following Information/Records: (please check all that apply):
Grades, Unofficial Transcripts and other Academic Information – If a student has signed waiver, grades, unofficial
transcripts, and other academic information can be mailed to the permanent address on file.
Financial Information – Financial Aid information including application and award status.
Athletic Information – Any other information about an athlete not included in the directory information.
Lodges – Money matters, behavior, health and safety.
Advising – Progress and dismissal information, class issues, GPA, etc.
Billing Information – How much a student owes to the College and for what.
Begin Date: End Date: or Term:
Date of Birth: Student ID#: S00 or SSN:
Student Signature: Date: