Lehigh Carbon
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COMMUNITY
COLLEGE
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Authorization for Release of Information
Please use black or blue ink, NO PENCIL
Registration/Student Records
4525 Education Park Drive, Room SSC 122
Schnecksville, PA 18078
Last Name First Name MI
www.lccc.edu
Phone: 610-799-1171 Fax: 610-799-1173
Student ID Number Date
RETURN FORM TO: Registration/Student Records Office for processing.
Consent for FULL ACCESS to Educational Records.
(Full access does not give
authority to make changes to the student's
educational record.)
Consent for LIMITED ACCESS to Educational Records.
(Limited access does not give
authority to make changes to the student's
educational record.)
Only my Lehigh Carbon Community College transcript.
The following specific information or records:
Purpose for the Authorization (please explain)
Provide full name and address of agent [individual(s) or agency] to whom access
to records may be provided:
I understand that some of my records may be protected under the Family Educational
Rights and Privacy Act of 1974 and cannot be released without my written consent.
I hereby waive all provisions of the law and privilege relating to the records described in
this disclosure. I certify that this consent has been given freely and voluntarily. I may
revoke this consent at any time by providing written notice of such revocation to the
Registration/Student Records Office. This authorization is good for one year from the date I
sign this release, unless noted differently, and photocopies of this release form may be
accepted, when presented in person with appropriate identification. The person and/or
agency receiving this information may not disclose the information received as a result of
this disclosure unless specifically authorized in the "purpose" section of this release.
Student's Signature Date
One-time Use: This authorization can be used only once.
Limited Use: This authorization expires on
Long-term Use: This authorization will remain continuously in effect until
I withdraw this authorization in writing.
For Registration/Student Records Office Use Only:
Processed by: Date:
Comments:
PERM33B-ll (8/3/18)
