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.
___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
__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.
SCOPE OF CONSENT
I hereby authorize the release of information indicated below to those entities name on this
__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