Fillable I understand the information below will be kept (Illinois Central College)

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I understand the information below will be kept (Illinois Central College)

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Office Use ONLY
Received By: _________________________________________________________Date: __________________________
Processed By: _________________________________________________________Date: __________________________
Name: _____________________________________________________________________________________________
ICC Student ID: _________________________________________ Date of Birth: _________________________________
Purpose of Release: ___________________________________________________________________________________
I understand the information below will be kept confidential and will not be shared with any other agency without my consent.
An authorized Illinois Central College staff member has my permission to release the following information:
____ All of the following items listed ____ Grades
____ Academic Standing ____ Instructors / Advisor Comments
____ Class Schedule ____ Number of Hours Enrolled
____ Enrollment Status ____ Refund Information
____ Financial Aid ____ Tuition payment information
Information indicated above may be released to:
Name: _____________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Address (2): _________________________________________________________________________________________
City: ______________________________________________State: ___________________Zip Code: ________________
E-Mail Address: _______________________________________________________________________________________
Name: _____________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Address (2): _________________________________________________________________________________________
City: _______________________________________________State: ___________________Zip Code: _______________
E-Mail Address: _______________________________________________________________________________________
Name: _____________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Address (2): _________________________________________________________________________________________
City: ______________________________________________State: ___________________Zip Code: ________________
E-Mail Address: _______________________________________________________________________________________
I understand that this document is valid until I request removal.
Student Signature: _____________________________________________________Date: _________________________
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I understand the information below will be kept (Illinois Central College)

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Completed 25 July 2020

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