Fillable RELEASE OF INFORMATION (Laramie County Community College)

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RELEASE OF INFORMATION (Laramie County Community College)

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LARAMIE COUNTY COMMUNITY COLLEGE
RELEASE OF INFORMATION
_________________________________________________________ Student ID Number ________________
               (print full legal name)
I hereby authorize Laramie County Community College to release all informaon for the 20___-20___ and 20___-20___ academic
year(s) regarding billing, nancial aid, grades, class schedule, or all.
I also authorize LCCC to allow the below individuals to perform registraon transacons (adding/dropping classes) on my behalf.
Name ____________________________________________________ Relaonship _______________________________________
Name ____________________________________________________ Relaonship _______________________________________
For account security, you must also specify an account authorizaon password. The above listed individual(s) must know this
password as well as your name and ID number in order for LCCC to release any informaon to them. The password should be one
word; it can contain numbers, but not special symbols or characters. The word “password” is not acceptable.
Password: ________________________
I authorize the release of this informaon for the purpose of paying my bill, monitoring my account and/or checking on my progress at
Laramie County Community College. This authorizaon does not permit anyone to request transcripts on a student’s behalf.
I understand that this release of informaon may be revoked at any me by contacng the LCCC Student Hub and that this release
covers only the terms indicated and must be re-submied if LCCC is to disclose informaon past the me frame indicated on this form.
Signature _____________________________________________ Date _____________________
Instrucons and turn-in opons:
You must print and physically sign this form (digital signatures are not accepted).
You can return this form in-person at the Student Hub in either Cheyenne or Laramie,
via mail to: Laramie County Community College
Student Hub
1400 E. College Dr.
Cheyenne, WY 82007
-OR- scan and submit it digitally via our secure dropbox at hps://lccc.sendsafely.com/dropzone/studenthub
PRS 5773 2/20
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RELEASE OF INFORMATION (Laramie County Community College)

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Completed 4 February 2021

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