ADMISSIONS & RECORDS OFFICE
4000 South Rose Ave Oxnard, CA 93033 PHONE: (805) 678-5810
Authorization to Release Information
Student Name:
_
Student ID: _
Phone Number: ___________________________ Date of Birth:________________________
Official Transcript Current Semester Enrollment Information Past Enrollment Information
Contents of Permanent Record Academic Standing/GPA Information
Other (please specify below)
Name ______________________________________ Organization/Agency
__________________________________________
Address____________________________________________
City
__________________
State_________ Zip Code____________
Organization/Agency name and affiliated address information is only required when there is a request to mail documents.
x Date:
x Date:
Authorization to Release Information 4/20/2018
Office Use Only: Documents mailed or picked up
A&R Signature: ____________________________________________ Date: ________________________________
Authorized Recipient Signature: As proof of receipt of the student documents.
Student Signature:
Authorized Recipient: A valid Photo ID is required with any in person transaction.
Information to be Released:
STUDENT INSTRUCTIONS:
By completing and signing this form, you are authorizing the one time release of your academic information to the individual(s)
you have specified and that individual may act as your agent during this transaction. A new form must be filled out each time
you seek to authorize the release of your academic information.
PERMISSION REQUIREMENT:
In accordance with the Family Educational Rights and Privacy Act of 1974, also known as FERPA or the Buckley Amendment, the
confidentiality and privacy of the academic records of our students must be maintained. Student record information cannot be
released to anyone without the student’s written consent. The federal law applies to all students attending any college within
the Ventura County Community College District, regardless of their age.
