Consent for Release of Student Information
Rev. 5/21/19
Student Name: __________________________________________________Student ID: _________________
Last First Middle
I, the above named student, hereby authorize North Idaho College to release the following information to the
individual indicated below. Please check all that apply.
Complete access to all records with no exceptions
Academic records Admissions records Advising records Attendance records
Billing records Course schedule Disability records Disciplinary records
Financial Aid records Graduation records Residence Hall records Transfer institutions
Other (please specify):
Please indicate the individual to whom the above information may be released to upon request. If you would
like to authorize release of different information to another individual please complete an additional form.
_________________________________________________________________________________________
Last First Middle Relationship to Student
_________________________________________________________________________________________
Street Address City State Zip Phone Number
_________________________________________________________________________________________
Email Address
In order to ensure secure access to your records, we require the creation of a security question and answer that
you
share only with the individual you have designated to have access to your records. The individual must
know the answer to this security question in order to gain access to the records you have granted. It should not
be a question to which the answer is common knowledge.
Security Question:___________________________________________ Answer: ________________________
I understand that this information is considered a student education, financial, and/or housing record. Further, I understand that by
signing this release, I am waiving my right to keep this information confidential under the Family Education Rights and Privacy Act
(FERPA). I certify that my consent for disclosure of this information is entirely voluntary. I understand this consent for disclosure of
information can be revoked by me in writing at any time, but will not affect the information released under my previous consent. If I
wish to make any changes to my consent for release, I understand I will need to complete and file a new form.
Student’s Signature:_________________________________________________ Date:___________________
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Only complete this section to revoke the above individual’s access to your information at a later date.
I revoke my permission for release of information to the above named individual.
Student’s Signature:_________________________________________________ Date:___________________
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The student’s current photo ID must be shown when submitting this form. If the form is mailed or faxed back
please include a copy of the student’s photo ID that includes a signature, such as a Driver’s License.
For Registrar’s Office
Use Only
Updated by______________
Date____________________
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