JOHN A. LOGAN COLLEGE
CONSENT TO USE AND DISCLOSE STUDENT RECORDS AND/OR INFORMATION
Student Name: _____________________ Student ID #:___________________
IDENTITY OF DISCLOSURE:
__I give consent to the person(s) and/or organization(s) indentified below to disclose
records and/or information to John A. Logan College for its use in implementing my
educational program and/or related employment goals.
___________________________ ____________________________________
Name Address
___________________________ ____________________________________
Name Address
___Any Educational Institution
PURPOSE OF DISCLOSURE
The purpose of disclosing the information specified about is (check all that apply)
__To provide records and/or other information to the designated person(s) or organization(s) regarding
the Student’s educational program and/or employment goals for use by the person(s) or organization(s).
__ To assist John A. Logan College in implementing Student’s education program and/or employment
goals.
__A review of medical, psychological or other information of Student regarding or relating to Student’s
request for a reasonable accommodation/modification or auxiliary aid/service to a John A. Logan College
program or activity.
__To assist John A. Logan College coaches in answering recruiting questions from other educational
institutions interested in recruiting Student as an athlete following Student’s graduation.
__Other (specify)
____________________________________________________________________
____________________________________________________________________
SCOPE OF CONSENT
I hereby authorize the release of information indicated below to those entities name on this
document:
__Advising Information __Attendance
__Business Office Information (e.g. fee statement) __Course Schedules
__Disciplinary or Personal Conduct Actions __Criminal Background Information
__Financial Aid Information __Grades
__Individual Education/Employment Plans __Injury/Incident Reports
__Online Account Access __Placement/Test Scores
__Progress Information __Transcript
RIGHT TO INSPECT, COPY, REFUSE CONSENT
I understand that pursuant to this Consent, I have the right to inspect the records released by John A.
Logan College and to copy such records. I also understand that I may refuse to sign this Consent and that
my refusal to sign will not affect my educational rights or eligibility for benefits offered or provided by
John A. Logan College. I further understand that my refusal to consent to the release of records and/or
information specified in the Consent will prevent disclosure of such information. I further understand that
such refusal may result in depriving John A. Logan College of information that would assist it in
implementation of my educational program and/or employment goals, or depriving the third-party
person(s) or organization(s) identified in this Consent of information.
NONDISCLOSRE:
I understand that records and/or information which is (are) released to John A. Logan College pursuant to
this Consent, will not be disclosed to third-parties, except as otherwise provided by law or court order or
unless I provide a subsequent valid written Consent. I further understand that If the person or organization
to whom individually identifiable health information is disclosed is not a health plan or health care
provider, or if the information does not relate to a federally funded substance abuse program, the
information may no longer be protected by federal privacy law and regulations after disclosure. In such a
case, the information may be disclosed by the recipient to others for other purposes.
REVOCATION:
I understand that I have the right to revoke this Consent at anytime. I further understand that any
revocation shall be made in writing, signed by me and the signature witnessed by an individual who can
attest to my identity. No written revocation of consent shall be effective until received by the person(s)
authorized to make disclosure of records and information pursuant to this Consent. Any such revocation
shall have no effect on disclosures made prior to my revocation. Revocation should be made to the Office
of the Director of Registrar Services.
UNDERSTANDING VOLUNTARY CONSENT:
I have read and understood this Consent and hereby voluntary consent to the release and exchange of
information as set forth in this Consent. I further understand that this Consent is valid and in effect
indefinitely unless otherwise revoked by me per the procedure outlined above.
________________________________ ____________ _____________________
Student Signature Date Witness
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