Student Services • Phone 907-262-0330 • Fax 907-262-0322
156 College Road • Soldotna, AK 99669
Authorization to Release Education Record Information
UA is an AA/EO employer and educational institution and prohibits illegal discrimination against any
individual: www.alaska.edu/titleIXcompliance/nondiscrimination.
Requested By (Student): Release To (Recipient/s):
LAST NAME FIRST NAME MI LAST NAME FIRST NAME MI
UA ID NUMBER LAST NAME FIRST NAME MI
DATE
*If submitting via fax or mail, a government
RELATIONSHIP TO STUDENT
issued ID must be included or this form will not
be processed.
By signing below, the student gives permission for Kenai Peninsula College to release the SELECTED items to the recipient/s listed above.
ACADEMIC RECORDS
Includes courses taken, grades received, GPA, academic progress, honors (including Dean’s list), transfer credit awarded and degrees awarded.
ACCOUNTING
Includes tuition and fee balances, financial holds, mailing & billing address information, payment plans, accounting statements, collections
information and detailed debt information.
ADMISSIONS
Includes date of application, program selected, documents received, documents pending, date of admission, admission status, catalog year and
correspondence sent to student. This applies only to a student who is currently attending or once attended KPC or UAA.
FINANCIAL AID
Includes general financial aid information, tax information, financial aid award letter and financial aid refund/check amounts.
REGISTRATION
Includes current enrollment (including days, times and location of enrolled courses), dates of enrollment activity (including add/drop/withdrawal
dates), enrollment status, residency status, semesters attended and mailing address information.
STUDENT EMPLOYMENT
Includes student job information and payroll information.
ALL ITEMS ABOVE
STUDENT SIGNATURE DATE
THIS AUTHORIZATION IS VALID UNTIL A WRITTEN REQUEST TO RESCIND IS RECEIVED BY KPC STUDENT SERVICES.
** For Official Use Only **
ID type: ______________________ Verified By:____________________________ Date:_____________________
click to sign
signature
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