Student Enrollment & Financial Services
Authorization for Release of Information to Others
Student’s Name (please print) _____________________________________________________________________________
Last First Middle Initial
Student’s ID No.: ______________________________ Student’s E-mail: _______________________________
Phone __________________________ Previous Names (if any)_________________________________________________
*I hereby authorize Mission College to release information from my Mission College academic or financial records to:
Please print: Last name First name Last name First name
Relationship to Student: ____________________ Relationship to Student: ________________________
By my signature below, I acknowledge that this release allows Mission College staff to release information from my official Mission
College education records to the person(s) listed above. Examples of the documents include transcripts, verification of enrollment,
class schedules, etc. I also acknowledge that is form is valid for one year from the signed date below.
By my signature below, I also acknowledge that this release does not authorize or entitle the person(s) listed above to advocate or
negotiate with college faculty, staff, and administrators on my behalf regarding college grades, records, disciplinary procedures, or
actions related to academic standing.
Student Signature X________________________________ Date ______________________
Picture ID Required. State and Federal regulations prohibit release of information without the student’s written authorization.
Office Use Only
ID Type: __________________________________
Verified By: ____________ Date: __________________