Fillable Northridge Student Housing Student Authorization to Release Information (California State University, Northridge)

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Northridge Student Housing Student Authorization to Release Information (California State University, Northridge)

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The Northridge Student Housing Student Authorization to Release Information (California State University, Northridge) form is 1 page long and contains:

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California
State
U
niversit
y
Northridge
Student Housing
17950 Lassen Street. Northridge, CA 91325 Ph: 818-677-2160 Fax: 818-677-4888
Student Authorization to Release Information
By signing below and supplying confidential information as an identifier, I authorize Student Housing to release
information from my University records to the following person(s):
Release Information to:
Name: _________________________________________________________________________
Address: _______________________________________________________________________
Relationship to Student: ____________________________________________________________
What is the purpose of this disclosure: ________________________________________________
Student Information:
Name______________________________________ CSUN ID____________________________
Month and
Day of Birth __________________________________________________________________
This authorization applies to all parental information regarding:
Student Housing
This authorization is in effect until I request, in writing, that it be rescinded or until the end of academic year
during which it was issued, whichever comes first.
In the event information is released in error, the undersigned agrees to hold CSU, Northridge harmless for
damages.
Student Signature_______________________________________________Date__________________
Submit this form in person to
Student Housing
Building 6, Pacific Willow Hall
17950 Lassen St.
Northridge, CA 91325
Forms not submitted in person to a Student Housing staff member must be notarized.
Authorization Coded: Authorization Terminated:
Date: _________________ Date: ___________________
ID Check/Notarization
By: __________________ By: _____________________
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Northridge Student Housing Student Authorization to Release Information (California State University, Northridge)

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Completed 18 August 2020

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