RELEASE OF STUDENT INFORMATION
Name of Student: ______________________________________________________________________________________________
Last Name First Name Middle Initial
Student ID Number: ______________________________________ Date: _____________________
This form is valid for one year. If valid for more or less than one year, please identify beginning and ending dates: _____________ to ____________.
This form allows students to grant access to their educational records maintained by the college’s Records and Registration Office,
Business Office and/or Financial Aid Office to another person, agency or school. Check the box(es) that apply below.
☐ Access to all educational records
or
☐ Access to specific educational records only (please specify): ______________________________________________________
The college prohibits the release of certain aspects of student records (e.g., grades, unofficial/official transcripts) via phone, e-mail
and/or fax. The college also prohibits the release of student ID numbers and login information.
This access/permission may be granted to: (List full name, address, and date of birth (DOB) if applicable for each person, agency or
school. Person must provide photo ID if accessing records in-person.)
Name: _____________________________________________________ DOB (if applicable): ________________________________
Address: ___________________________________________________________________________________________________
Name: _____________________________________________________ DOB (if applicable): ________________________________
Address: ___________________________________________________________________________________________________
☐ Northern Arizona Vocational Institute of Technology (NAVIT), 951 West Snowflake Blvd., Snowflake, AZ 85937
Check the box above if you wish to include NAVIT in the release of student information.
I hereby give my permission for Northland Pioneer College (NPC) to
release the information above to the specific person, agency or school
as indicated. I understand that this information may be released directly
to any entity named above either in writing or by telephone after
making a reasonable attempt to verify the identity of the person.
(Signature of Student- Required) Date
I hereby authorize the above entity to act as my proxy to process
transactions at NPC following a reasonable attempt by the college to
verify the identity of the person. I further understand that I am
responsible for any decisions made by my proxy on my behalf. I
understand that I remain responsible for complying with all applicable
requirements, policies, deadlines, charges, penalties, or grades.
(Signature of Student- Required) Date
Official Witness (NPC/NAVIT/school representative) Printed Name
Site
Date
A Notary Public must be used if not witnessed by an NPC/NAVIT/school representative.
State of Arizona )
) SS:
County of )
On this, the date of , 20 , before me a notary public, the undersigned officer, personally appeared ,
known to me or who has produced (type) as identification, to be the person whose name is subscribed to the within instrument,
and acknowledged that he/she executed the same for the purposes therein contained.
In witness hereof, I hereunto set my hand and official seal.
Notary Public
My commission expires on the day
of
, 20
I hereby give my permission for Northern Arizona Vocational Institute of Technology (NAVIT) to release the NPC-provided information above to the specific person,
agency or school as indicated. I understand that this information may be released directly to any entity named above either in writing or by telephone after making a
reasonable attempt to verify the identity of the person. This form is valid for one year from the date of signature.
____________________________________________
(Signature of Student – Required) Date
Original form must be sent to the Records & Registration Office. Available for other college departments upon request.
PUBLIC NOTICE OF NONDISCRIMINATION: Northland Pioneer College does not discriminate on the basis of race, color, national origin, veteran status, religion, marital status, gender, age or disability in
admission or access to, or treatment or employment in its educational programs or activities. District grievance procedures will be followed for compliance with Title IX and Section 504 requirements. The Affirmative
Action Compliance Officer is the Director of Human Resources, 2251 E. Navajo Blvd., Holbrook, Arizona 86025, (800) 266-7845. The Section 504 Compliance Officer is the Coordinator of Disability Resource and Access,
1001 W. Deuce of Clubs, Show Low, Arizona 85901, (800) 266-7845. The lack of English language skills will not be a barrier to admission and participation in vocational education programs. Revised 9-12-14
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