DMACC
DES
MO
I
NES
AREA
COMMU
NITY
COLLEGE-
Return this completed form to:
International Student Office
2006 S. Ankeny Blvd.
Ankeny, IA 50023-3993
Or email: intlstudentoffice@dmacc.edu
INTERNATIONAL STUDENT
AUTHORIZATION FOR RELEASE OF INFORMATION
DMACC does not share any information regarding your student record without a written release from you. If you would
like DMACC to share your international information (I-20, financial documents, application status, etc.) with designated
people, you must complete and sign this form listing the name of the person as well as the kind of information that
DMACC can share. PLEASE NOTE: Information will not be given to anyone over the telephone. Information will
only be provided by mail to the address listed or in person (a photo ID is required).
Student’s Name (please print):
Student’s Date of Birth:
Student’s Current Address:
(Street)
(City/State/Zip Code)
Student’s Phone: _______________________________________________________________________
Email: ________________________________________________________________________________
I, , hereby authorize
the International Student Office at DMACC to disclose the following information:
_______ I-20 _______ Financial Documents _______ Application Status
_______ Other (must be specific):
This information will be provided to:
Name (or Institution):
Relationship to student:
Address:
(Street)
(City/State/Zip Code)
Phone:
Email:
Student’s Signature: Date:
(PRINT student’s full name)
*Pursuant to the Family Educational Rights and Privacy Act (FERPA), the Iowa Fair Information Practices Act, Iowa Code, Section 22.11 (1987) and
Des Moines Area Community College policy, Des Moines Area Community College (DMACC) does not release personally identifiable educational
information and/or records without the written permission of the person involved.
The release of this information is valid for one year from the date listed above.
Signatures verified:
Date_____________ Staff:_____________________________________
click to sign
signature
click to edit
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