Fillable Consent - Consent For Authroized Representative

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Consent - Consent For Authroized Representative

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BROWSE OTHERS (CANADA) FORMS

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J:\STUDENT\GraduationandPublications\Publications\For m s\ConsentforAuthorizedRepres entative08/2016

ConsentforAuthorizedRepresentative

Registrar&EnrolmentServices

STUDENTINFORMATION

LANGARAID:_________________________________________DATEOFBIRTH(MM/DD/YYYY):___________________________

LEGALSURNAME:_____________________________________LEGALFIRSTNAME:_____________________________________

REPRESENTATIVEINFORMATION



FULLNAMEOFPERSON/AGENCY:_______________________________________________________________________________



RELATIONSHIP:_______________________________________EMAIL*:______________________________________________



*Informationwillonlybesharedwiththisrepresentativeinpersonand/orbyemail.Ifyoudonotwishforinformationtobe

sharedbyemail,pleaseleavethisfieldblank.Emailinquirieswillonlyberespondedtoifsentfromthisaddress.



Thiswaiverwillbevalidforthefollowingperiod,oruntilIrevokeauthority:



From:_______________________________________________To:__________________________________________________

STUDENTINFORMATION

Iauthorizetheperson/agencystatedaboveaccesstothefollowinginformation:

Academicstanding

Applicationstatus

Finalgrades

Graduationrequirements

Registrationinformation(includingcurrentregistrationstatus)

Specialneedsdocumentationordisabilityaccommodations



Other(specify):___________________________________

FINANCIALINFORMATION

Iauthorizetheperson/agencystatedaboveaccesstothefollowinginformation:

Studentaccountbalance

Studentawards

Studentloaninformation

Tuitionandfeesassessment



Other(specify):___________________________________

STUDENTTRANSACTIONS



Iauthorizetheperson/agencystatedabovetocarryoutthefollowingtransactionsonmybehalf:

Ordertranscripts,confirmationofenrolmentletters,RESPforms,etc.

Pickuptranscripts,confirmationofenrolmentletters,RESPforms,etc.



Other(specify):___________________________________

CONDITIONS

1. IunderstandthattheAuthorizedRepresentativeispermittedtorepresentmeuptoandincludingtheenddateIhave

selected.

2. IunderstandthatLangaraCollegecollects,usesanddisclosesmypersonalinformationincompliancewiththeprovisionsof

theBritishColumbiaFreedomofInformationandProtectionofPrivacyAct[RSBC1

996,Chapter152]andwillusethe

informationforresearchandstatisticalpurposessubjecttotheprovisionsoftheAct.

3. IunderstandthatifIwishtoextendtheauthorizationperiodIhaveselectedabove,itismyresponsibilitytosubmitanew

ConsentforAuthorizedRepresentativeform.

4. Iun

derstandthatanyrequesttocancelthisauthorizationbeforetheenddateIhaveselectedabovemustbesubmittedin

writing.

5. IunderstandthatifIhavealreadysubmittedaConsentforAuthorizedRepresentativeform,thisformoverridestheprevious

one.

6. Ihavereadandunderstoodth

eabovestatements.



STUDENT’SSIGNATURE:_______________________________________________________DATE:_____________________

SUBMITCOMPLETEDFORM

Inpersonto:Registrar&EnrolmentServices,LangaraCollege,100West49

Ave.,Vancouver,BCV5Y2Z6

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Completed 19 October 2020

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