Admissions Ph: (808) 845-9129
HONOLULU COMMUNITY COLLEGE
Admissions Fax: (808) 847-9829
Records Ph: (808) 845-9120
Records Fax: (808) 847-9872
Honolulu Community College must follow all applicable state and federal laws (FERPA), rules and regulations that apply to student records.
Therefore, all information contained in the college records which is personally identifiable to any student shall be kept confidential and not
released except upon prior written consent of the student or upon the lawful subpoena or other order of a court of competent jurisdiction.
This release will be valid until the student invalidates it by completing a new form.
Student Information – Please print clearly
Name: _______________________________________
First Name Middle Initial Last Name
Address: _____________________________________
Street Address
_____________________________________________
City State Zip Code
Phone Number: ___________ Date of Birth: ________
UH Student ID #: _______________________________
Please release the following records
(Check all that apply):
Other (please list): _____________________________________
Restrictions (if any): ____________________________
Release Information to:
Name: _______________________________________
First Name Middle Initial Last Name
Address: _____________________________________
Street Address
_____________________________________________
City State Zip Code
Phone Number: ________________________________
Fax Number: __________________________________
E-Mail Address: ________________________________
Relationship to Student: _________________________
Security Code*: ________________________________
*What is a Security Code? This code allows the
individual(s) you have listed to access your information if
they contact the college. The code may be up to nine
characters long. Honolulu Community College will not
release protected information over the phone unless the
person can provide the Security Code. To update
permissions, please submit a new consent to release form.
Office Use Only:
Received by (Initials): _______ Entered in SPACMNT on: _______ Inputted by (Initials): _______
Form last updated on 2/6/2019
I hereby authorize Honolulu Community College to
release confidential information about me
contained in the college’s records. I agree to hold
Honolulu Community College and its employees
harmless for any unauthorized use of my student
records obtained by the indicated parties.
____________________________ _____________
Signature Date
TO SUBMIT:
Completed forms can be dropped off to the Admissions &
Records Office. Forms can also be mailed. Please attach
copy of valid ID to confirm signature.
Release Information to:
Name: _______________________________________
First Name Middle Initial Last Name
Address: _____________________________________
Street Address
_____________________________________________
City State Zip Code
Phone Number: ________________________________
Fax Number: __________________________________
E-Mail Address: ________________________________
Relationship to Student: _________________________
Security Code*: ________________________________
