Student Record Release Authorization
I, ___________________________________ hereby authorize Cerritos College to release information
contained in my student record(s) per the provisions, purposes and/or limitations listed below to the
following designee: ___________________________ (Designee must bring in photo identification.)
Type of Information requested (check one):
Enrollment Verification
Other (be specific):
The Purpose(s) of this authorization are (check one):
At the discretion of the aforementioned designee.
Limited to the following (be specific):
(Legal Student Signature)
(Student ID Number)
In accordance with General Education Provisions Act 438, Title IV, Public Law 90-247
and California Education Code, Sections 76240-76246, we must have written authori-
zation from the student to release information regarding educational records.
Students: Please complete this form and have your designee submit it to the office of
Admissions, Records, & Services.
Designee: Must bring in a valid form of photo identification.
Office of Admissions, Records, & Services
College Bridge
Updated 5/13/2011 DB