Student Authorization to Release Education
Records to a Third Party
______________________________________________ ______________
Print Student’s Name: JU ID#
Circle item(s) of information to be released:
Academic Financial Student Life
The information may be released to the following person(s) or organization(s):
1. ______________________________________________________________________
Name Relationship
2. ______________________________________________________________________
Name Relationship
Provide a code word/number to be used when asked to release information over the phone.
___________________________
I hereby grant authorization to Jacksonville University to release my above-referenced
education records to the party or parties listed on this form.
______________________________________________ ___
Student’s Signature Date
This form must be submitted by the student to the Registrar's Office, 1
st
floor of
the Howard Administration Building. The student will be required to show their
JU ID card at time of submission.
Authorization Release Records Third Party 9-23-08/Forms/Letters & Forms/Regshare
Updated: 6/7/2011
