Fillable Early College Programs Student Consent for Release of

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Early College Programs Student Consent for Release of

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The Early College Programs Student Consent for Release of form is 1 page long and contains:

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  • 15 check-boxes
  • 22 other fields

Country of origin: US
File type: PDF

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For CEI use only: Revised 11.28..18
☐ EC Verified ☐ Sponsorship Entered (BO Office) ☐ Early College Programs Office (Perc added)
Early College Programs Student Consent for Release of Non-Directory Information
College of Eastern Idaho Records Policy, in compliance with the Family Educational Rights and Privacy Act of 1974
(FERPA), requires the written consent of the student authorizing the disclosure of non-directory information from his or
her record. The authorization must include: the specific information to be released; the party or class of parties to whom the
information is to be released; the purpose of the release; the date; and the student’s signature.
PHOTO ID IS REQUIRED. Students must present photo ID when submitting this form in-person, or provide a copy of
photo ID when submitting the form via mail, fax or email.
(PRINT or TYPE All Information CLEARLY, Using Ink Only)
1. Student Contact Information
Name
Date
Student ID#
Phone
Date of Birth
2. Release Education Record Information to (Recipient):
Last Name
First Name
Organization/School
Relationship
Address
City
State
Zip
3. Type of Release (Check one):
☐ One-time release of student records.
☐ Release of student records until revoked by me in writing and delivered to CEI.
(Note: if you have signed a confidentiality request for your directory information, you must submit a one-time
only release for each release of information.)
☐ I wish to revoke the current release of information I have on record for the following
person/institution:
4. Education Record to be Released (Check all that apply):
☐ Attendance
☐ Billing Statements
☐ Class Schedule
☐ Financial Aid
☐ Grades/GPA
☐ Program Information
☐ Status Information
☐ All of the Above
☐ Other- please specify
5. Signature
I give permission to College of Eastern Idaho (CEI) to release the specified information to the recipient listed above. I
understand that this information is considered part of a student education and/or financial 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 Signature
Date
For CEI Use Only
Initial
Dept.
Date
Note: by signing this you are confirming that you have verified photo ID. After entering the release of information in
Colleague, have the form scanned and place in students file.
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Early College Programs
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Completed 25 July 2020

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