I, , authorize Antioch University to provide the individuals listed below with
access to the selected educational records:
Initial on the line(s) verifying which records you wish to make available to the individuals authorized on this form.
Financial Aid Records. Example records include award and disbursement information, satisfactory academic
progress, financial aid file status, financial aid request form, and any other documents maintained within the financial aid file.
Academic Records. Example records include academic transcript, evaluator learning assessments, clinical training
verification documents, registration documents, admission documents, satisfactory academic progress, and any other documents
maintained within the academic file.
Student Account Records. Example records include tuition and fee charges, payment sources and amounts,
financial holds, and any other information maintained within the student accounts file.
The following individuals have authorization to access the records initialed above:
Last Name First Name Relation Contact Number
Last Name First Name Relation Contact Number
Last Name First Name Relation Contact Number
Authorization is effective the date the form is signed by the student. Authorization is valid until revoked. You may revoke the
right to access by submitting an official statement to the Registrar’s Office via your Antioch.edu email account.
Student ID Number
Student Signature* Date
*Please note that an electronic signature is only valid when using an Antioch email account.
Please submit completed form to the AUS Student Services Office.
2400 3rd Ave, Suite 200,
Seattle WA 98121
206.268.4202 (phone)
206.268.4242 (fax)
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