Clarion University of Pennsylvania
Release of Information
Return completed form to:
In Person: Clarion Campus By mail: Clarion University of PA
148 Becht Hall Registrar's Office
By Email: registrar@clarion.edu 840 Wood Street
By Fax: 814-393-2039 Clarion, PA 16214
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__________________________________ _________________________________________
Student’s Name (Please Print) Clarion ID Number
The R
elease 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. Please check the appropriate box below:
ADD CHANGE DELETE
1. __
_____________________________________
Name of Authorized Parent or Legal Guardian
________________________________________
2. _______________________________________
Name of Authorized Parent or Legal Guardian
_________________________________________
Address Address
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_______________ _______ _________ ______________________ _______ _________
City State Zip Code City State Zip Code
_________________________________________ _________________________________________
Relationship to Student Relationship to Student
(Ex. Mother, Father, Legal Guardian, etc.) (Ex. Mother, Father, Legal Guardian, etc.)
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__________________________________ __________________________________________
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.
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_______________________________________________ ____________________________________
Student’s Signature
Date
Office Use Only
Note: Parental names and addresses are also used to keep
parents apprised of university news, events, and information.
