Iowa Lakes Community College
RELEASE OF SECURE INFORMATION
In compliance with FERPA, and the college’s policy on access to student education records, the college is prohibited from providing
certain information from your student records to a third party, such as information on grades, billing, tuition and fees, assessments,
financial records (including scholarships, grants, work study, or loan amounts) and other student record information. This restriction
applies but is not limited to your parents, guardian, your spouse, or a sponsor.
By my signature below, I authorize college staff members to release the following secured
information in my student record to selected third party:
Indicate the specific contents of the record to be released
☐All Information
☐Grades
☐Registration/Schedule
☐Billing
☐Financial Aid
☐Housing/Dorm information
☐Other:
Third Party information:
Mailing Address/email
We will only release info to the mailing or email
address listed on this form.
Privacy Code-
Code will be asked
when third party
contacts the college
via phone or email
This authorization is in effect until rescinded in writing by notice to the college records office.
This authorization is no longer in effect once the student is no longer registered as a student at
Iowa Lakes Community College.
Printed Name ______________________________________________ ID# ____________________________
Signature _________________________________________________ Date _______________________________
NOTE:
This completed form may be emailed to the Records office at records@iowalakes.edu using
your official Iowa Lakes email address.
If you are not using your official Iowa Lakes email, print off the form, fill it out, sign it, scan it
and attach it to your email.
Rev. 03/14/19
click to sign
signature
click to edit
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