Fillable Release Of Information Form (Central Community College)

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Release Of Information Form (Central Community College)

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The Release Of Information Form (Central Community College) form is 1 page long and contains:

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Country of origin: US
File type: PDF

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BROWSE CENTRAL COMMUNITY COLLEGE FORMS

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Release of Information
The Family Educational Rights and Privacy Act (FERPA) bars an educational institution from releasing confidential information
about a student—including information about and assessments of her/his academic performance—without the student’s express
written consent. You may waive this right by completing this form. You have the right to deactivate this waiver at any time. If you at
any time wish to reverse this decision, please complete another Release of Information form.
First Name
Last Name
MI
CCC ID Number or
Date of Birth
Address
State
Zip
The following records may be released/discussed:
All of my educational records maintained at Central Community College
OR
This consent is limited to the records indicated below (Check all that apply)
Grades, credits, grade point average
Progress reports
Test or assessment results
Academic advising records
Disciplinary charges and proceedings
Financial aid records
Personal counseling records
Other Specify________________________
Student financial information
Please release the above information to the following:
Name:
Name:
Address:
Address
City, ST Zip
City, ST Zip
Name:
Name:
Address:
Address
City, ST Zip
City, ST Zip
Central Community College has my consent to release my information.
Student Signature
Date
Please bring this signed form to the Registration Office on campus or fax/mail to the following address:
College Registrar Scan and email to: LinkingReg@cccneb.edu
Central Community College
PO Box 4903
Grand Island, NE 68802-4903
Office Use: Entered in STRK_______ 10/18
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Release Of Information Form (Central Community College)

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Completed 29 January 2021

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