Clarion University of Pennsylvania
Release of Information
Return completed form to:
In Person: Clarion Campus By mail or fax: Clarion University of PA
Becht Lobby Registrar's Office
Resource Desk 840 Wood Street
Clarion, PA 16214
814-393-2039
The Release of Information Form permits Clarion University to release my academic records, which include grade transcripts, class
attendance information, student personnel records, credential files, financial aid records, and student accounting records, to my
parent(s) or legal guardian(s) as listed below upon written request from them.
Student's Name (please print) Clarion ID Number
1. 2.
Name of Authorized Parent or Legal Guardian Name of Authorized Parent or Legal Guardian
Address Address
City State Zip Code Zip CodeStateCity
Relationship to Student
(Ex. Mother, Father, Legal Guardian, etc.)
Relationship to Student
(Ex. Mother, Father, Legal Guardian, etc.)
Telephone Number
Telephone Number
I give permission for Clarion University to release my education records to the individuals listed above for the purposes of supporting
my educational goals. The release does not permit disclosure of my student records to any other persons or entities without my
written consent, unless authorized by the Family Educational Rights and Privacy Act of 1974 which permits release to Clarion
University school officials who demonstrate a legitimate educational interest. This authorization does not pertain to medical,
counseling, or psychiatric records. I accept responsibility for notifying the Office of the Registrar, in writing, if this authorization
should change. I understand it will remain in effect throughout my undergraduate enrollment at Clarion University.
DateStudent's Signature
Note: Parental names and addresses are also used to keep parents
apprised of university news, events, and information.
Office Use Only
MF F M MSF FSM
SF SM PSF PSM LG
