Fillable Permission to Discuss/Release Education Record Information (Bradley University)

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Permission to Discuss/Release Education Record Information (Bradley University)

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Permission to Discuss/Release Education Record Information
Requested by (Student): Discuss with and/or Release to:
_______________________________________________ ___________________________________________________
Last First Last First
______________________________
Student ID #
Education record information to be released (be specific):
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Purpose of the release:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
I give permission for__________________________________________________ to discuss the specified
information with the individual listed above. This is a one time release.
_________________________________________________________________ ______________________________
Student Signature Date
For office use only
Action taken:
By whom__________________________________________________________ Date________________________
Retain this release in the student file.
Permission to Discuss 07/31/2017
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Permission to DiscussRelease Education Record Information (Bradley University)

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Completed 18 August 2020

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