Admission and Records
Phone: (541) 383-7500
Fax: (541) 318-3700
Rev 1/22/18
I, , hereby permit Central Oregon Community College to release the
following information from my educational records. (Check all that apply)
The above information may be released by phone, in-person or in writing to the following individuals, once s/he has
confirmed my COCC identification number and date of birth.
I understand that the above information is considered private information under the federal FERPA (Family Educational
Rights and Privacy Act) guidelines. By completing and signing this form, I realize that this information will be released to
the party(ies) indicated and that this Release has no expiration date. I may revoke this release by providing a written
request to Enrollment Services. This release does NOT authorize others to make any changes to my COCC
account/record, including to add/drop classes or request transcripts on my behalf. Note: This release does not cover
the Services for Students with Disabilities (SSD) department. Students working with the SSD office need to
contact that office directly for a separate release.
Student Name (print) COCC ID Number
Student Email Address Student Phone Number
Student Signature Date
This form must be submitted either in person, with picture identification, to Enrollment Services at any campus OR via
fax (541-318- signature.
Office use only: ID Verification
Academic Performance/Progress
Class Schedule for Current Term
Cumulative Credit Hours
Financial Aid Information
Grades/Academic Standing
On Campus Housing Related Information
(Includes conduct issues)
Pre-Registration Activity
Payment Information/History
Registration History
Student Conduct Information
Other (Specify):
click to sign
click to edit