JACKSON STATE COMMUNITY COLLEGE CONSENT FOR
THE RELEASE OF ACADEMIC-RELATED INFORMATION FORM
STUDENT NAME:______________________________________ SS#:_________________________
Check one or both of the following as they apply:
I do hereby grant permission for my current instructors at Jackson State Community College to discuss
and/or disclose personally identifiable (academic-related) information to my natural or adopted parent(s).
I do hereby grant permission for my current instructors at Jackson State Community College to discuss
and/or disclose personally identifiable (academic-related) information to the person(s) below:
Name: _______________________________________ Relationship: _______________________
Name: _______________________________________ Relationship: _______________________
Please explain the purpose of this disclosure of personal information:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
I acknowledge that this consent form, if approved, is in effect for the one semester in which it was
signed until the first day of the ensuing semester.
I further understand that this consent form only applies to my academic information handled by my
instructor and that I must petition the Registrar for release of all other institutional records.
STUDENT SIGNATURE:________________________________ DATE:______________________
FOR USE BY THE JACKSON STATE RECORDS OFFICE:
APPROVED NOT APPROVED DATE: ___________________
*Note decision & date on SPACMNT and file original form in student’s file.*
