OFFICE OF THE UNIVERSITY REGISTRAR
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.
PERSONAL INFORMATION DISCLOSURE
AUTHORIZATION FORM
PERSONAL INFORMATION
PLEASE FILL IN ALL INFORMATION IN FULL
STUDENT ID NO.:
NAME:
BIRTH DATE:
MM __________ DD __________ YY___________
IDENTIFY INFORMATION AUTHORIZED FOR DISCLOSURE:
PERSON(S) OR ORGANIZATION:
RELATIONSHIP:
ADDRESS:
IN PERSON: BY FAX TRANSMISSION:
AS AN ATTACHED TO E-MAIL: SPECIFY E-MAIL ADDRESS IF THE LATTER IS APPROVED:
IF YOU WISH TO HAVE A FAMILY MEMBER, EMPLOYER, SPONSOR, DESIGNATED AGENT OR AGENCY, LEGAL COUNSEL OR OTHER PERSON
OBTAIN PERSONAL RECORDED INFORMATION ABOUT YOU IN THE CUSTODY OR UNDER THE CONTROL OF THE OFFICE OF THE UNIVERSITY
REGISTRAR IT IS NECESSARY THAT YOU COMPLETE THIS PERSONAL INFORMATION DISCLOSURE AUTHORIZATION FORM.
THIS CONSENT SHALL BE VALID FOR ONE YEAR FROM THE DATE OF AUTHORIZATION UNLESS A SHORTER TIME IS SPECIFIED ON THE FORM OR
IT IS REVOKED IN WRITING PRIOR TO THAT DATE.
I AUTHORIZE THIS RECORDED PERSONAL INFORMATION TO BE RELEASED BY THE FOLLOWING MEANS. INDICATE BY INITIALING IF
AUTHORIZED OR WRITE “NO”. OTHERWISE RELEASES WILL BE OF HARD COPY RECORDS ONLY BY MAIL OR IN PERSON PICK-UP. PICK-UPS
WILL REQUIRE THE INDIVIDUAL PRESENT PHOTO I.D. BEFORE INFORMATION IS RELEASED TO THEM.
I VOLUNTARILY REQUEST AND GIVE MY CONSENT TO THE DISCLOSURE OF THE SPECIFIED PERSONAL INFORMATION. I AM AWARE THAT I MAY
REVOKE MY CONSENT A
T ANY TIME BY DOING SO IN WRITING.
______________________________________________________________________
____________________________________________________________
SIGNATURE DATE
THIS IS TO IDENTIFY THAT I
REQUEST AND CONSENT TO THE RELEASE OF THE RECORDED INFORMATION SPECIFIED BELOW.
THIS INFORMATION IS TO BE RELEASED TO (IDENTIFY AN INDIVIDUAL OR A SPECIFIC ORGANIZATION/ OFFICE/
FUNCTION).
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 email account
FOR OFFICE USE ONLY
Processed By: ______________________________________
Date: ______________________________
