Madison College
Why CIE is
collecting this information:
1. Some international students use additional support during their application and admission process. We
need your permission to share admission and enrollment information with a friend or family member. By
signing this form, you are authorizing us to share information regarding your application checklist, visa, or
enrollment status.
2. We will not share any other information, such as your grades, disciplinary actions against you, and non-
emergency health information.
3. In any event, such as a safety or health emergency, the college is authorized to release some
information about you to select persons on a need to know basis.
Note: This permission is valid during the admission process only. After admission, if you would like information to
be released to an individual, you must complete a FERPA Release Form
NAL APPLICANT - Please complete the information below:
I, ____________________________, bo
rn on ________________, give permission for details regarding my
admission status to be shared with the following person:
First/Given Name: ____________________________ Last/Family Name: _______________________________
Relation to Applicant: ___________________________________________________________________________
Telephone Number: ___
______________________ Ema
il Address: ____________________________________
City: ____________________________________ Country: _____________________________________________
Disclaimer: The collection of this information does not in any way obligate the college to contact the person
above, or to share information.
(First/Given and Last/Family Name)
Applicant Signature: _________________________________________________ Date: __________________
Return completed form to:
Center for International Education (CIE) | Madison College
1701 Wright Street, Room
D1610, Madison WI 53704
(608) 246
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