Updated 2/22/19
Permission to Release Information
IMPORTANT NOTES—PLEASE READ!
Signing this release does not entitle the recipient to make transactions on behalf of the student (e.g. registrations, transcript orders,
etc.). It only enables the college to release the specified information to the recipient. Students are in control of their own educational
records and must complete their own transactions.
This form must be signed and submitted by the student via one of the following methods: 1) sent from CCC email account; 2) in person,
with photo ID, to Enrollment Services; or 3) via a college/school representative who has verified the student’s identity. We will not
accept this form via any other method.
STUDENT INFORMATION *Indicates required field
Name*________________________________________________________ Student ID/SSN*________________________________
Date of Birth*__________________________________________ Phone Number*_________________________________________
RECIPIENT INFORMATION (include full name)*
Family/Friend ______________________________________________________________________________________________
Mentor/Advisor/Counselor ____________________________________________________________________________________
Sponsor __________________________________________________________________________________________________
Employer _________________________________________________________________________________________________
C-TEC Youth Career Advisor __________________________________________________________________________________
WIOA/Workforce Advisor _____________________________________________________________________________________
Dept. of Human Services _____________________________________________________________________________________
Child Support Services ______________________________________________________________________________________
Other (please specify) _______________________________________________________________________________________
INFORMATION TO BE RELEASED*
Grades Only Student Account Information Financial Aid Information Academic Records
Disability Resource Center Information
All of the above (grades, student account info, financial aid info, academic records, Disability Resource Center info)
TIME PERIOD FOR RELEASE
Please indicate when you would like this release to expire: _____________________________________________________________
MM/DD/YY
Note: If left blank, we will use the end of the current academic year as the expiration date for this release.
Student Signature* _____________________________________________________ Date ______________________
Return completed form to:
EMAIL: registration@clackamas.edu
IN-PERSON: Enrollment Services, Roger Rook Hall, Oregon City campus
Student Services, Harmony East Building, Harmony Community campus
Student Services, Wilsonville campus
