CONSENT FOR ACCESS TO RECORDS
Virginia Military Survivors & Dependents Education Program
Dependent's Name (Last, First, Middle Initial): Date of Birth
IMPORTANT: You are not obliged to grant anyone access to information regarding you.
SECTION A: Information to be released (select all that apply):
Application Information (status, name and/or address changes)
Benefits Information (registration, enrollment status, stipend)
SECTION B: Person(s) to whom access to education records may be provided:
I hereby authorize the Department of Veterans Services/VMSDEP to release information checked in section A to the
following individuals:
SECTION C: Rights granted (select one):
I grant permission for the person(s) listed in section B to make changes to my application (name and address
changes, enrollment changes, etc.)
I do not grant permission for the person(s) listed in section B to make changes to my application (name and
address changes, enrollment changes, etc.)
SECTION D: Duration of release (cselect one):
One-time Use: This authorization can be used only once.
Limited Use: This authorization is valid from date of signing below until: ___________________________
Ongoing until written notice is given to VMSDEP to terminate.
SECTION E: Purpose of release (select all that apply):
VMSDEP Program eligibility
I understand that I have the right not to consent to the release of my records/information, and I have the right to
revoke this consent at any time by delivering a written revocation to the VMSDEP office.
Date: ____________________________ Dependent's Name: _________________________________________________
Dependent's Signature: ______________________________________________
Instructions for completing this form:
1. The form must be fully completed and signed by the dependent. Records cannot be released if any section of this
form is not filled out entirely.
2. Please upload this form to your myVMSDEP account. You may direct questions about this form to the VMSDEP Office
by phone at (804) 225 - 2083 or email at VMSDEP@dvs.virginia.gov.
This information is released subject to the confidentiality provisions of appropriate state and federal laws and regulations which prohibit any
further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by
such regulations.
Updated August 23, 2020
