OFFICE OF THE UNIVERSITY REGISTRAR
Mailing Address: P.O. Box 1796 • Edmonton, Alberta, Canada T5J 2P2
Phone: 780-497-5000 • Toll Free: 1-888-497-4622
www.MacEwan.ca • recordsunit@macewan.ca
FREEDOM OF INFORMATION & PROTECTION OF PRIVACY
Protection of Privacy - The personal information requested on this form is collected and protected under the authority of Part 2 of the Alberta Freedom of Information and Protection of
Privacy Act and the Post-Secondary Learning Act. It will be used for the enrollment process and student management consistent with that purpose. This information will be entered into and
retained in the ofcial university student information system database. Direct questions expressly related to the collection and use of this information to the Associate Registrar, Records,
Ofce of the University Registrar, MacEwan University, 10700-104 Avenue, Edmonton, AB, T5J 4S2, telephone 780-633-3110.
NON-DISCLOSURE OF PERSONAL
INFORMATION FORM
IF YOU WISH TO:
• HAVE MACEWAN UNIVERSITY NOT UTILIZE SECTION 17 (2)(J) TO ROUTINELY RELEASE THE TYPES OF INFORMATION LISTED BELOW, OR
• TO CANCEL A PREVIOUS SPECIAL CONSENT TO DISCLOSURE AUTHORIZATION,
PLEASE COMPLETE THE FOLLOWING DECLARATION AND SUBMIT IN PERSON TO THE OFFICE OF THE UNIVERSITY REGISTRAR.
I INSTRUCT MACEWAN UNIVERSITY NOT TO DISCLOSE (CHECK APPROPRIATE BOX(ES)):
ENROLMENT INFORMATION
EVENT OR ACTIVITY ATTENDANCE OR PARTICIPATION
RECEIPT OF HONOR OR AWARD
AND / OR REVOKE DISCLOSURE PERMISSION FOR _______________________________________________________________________________________
(IDENTIFY INDIVIDUAL TO WHOM PREVIOUS CONSENT HAS BEEN RELEASED)
FOR THE PERIOD (CHECK APPROPRIATE BOX):
PERMANENTLY
UNTIL COMPLETION OF STUDIES
UNTIL OTHERWISE DIRECTED
PERSONAL INFORMATION
PLEASE FILL IN ALL INFORMATION IN FULL (PLEASE PRINT)
STUDENT ID NO.: PROGRAM OF STUDY
FULL NAME: DATE:
SIGNATURE: _________________________________________________________________________________
PERSONAL INFORMATION COLLECTION NOTICE
The personal information requested on this form is collected under Section.33(c) of the Freedom of Information and Protection of Privacy Act for the purpose of one or all
of the following: to determine eligibility for admission and financial assistance, to advise students about academic programs and to provide university services at MacEwan
University. Questions concerning this collection should be directed to the Lead, Privacy and Information Management at privacy@macewan.ca
Signature not required if sent from a student @mymacewan.ca email account
Office Use Only
RECORDS - PROCESSED BY :___________________________________________
DATE PROCESSED: _____________________________
