Release of Information (ROI)
Student ID # Date
Student Name
Last First Middle
It is the policy of Columbia Basin College to honor all rights and to comply with all obligations arising under the Family Education
Rights and Privacy Act of 1974 (FERPA). Students who are attending a college are considered an “eligible student,” meaning the
rights to their academic records have transferred from the parent to the student. The Federal Family Education Rights and Privacy
Act (FERPA) prohibits the release of student information to anyone but the student without the student’s written permission to
do so. The Release of Information (ROI) authorizes the Registrar, or College designee, to discuss specific aspects of a student’s
academic record with the person(s) designated below.
This document does not authorize the person(s) designated to initiate or complete transactions, make changes to the student
record, or serve as a representative on the student’s behalf. The ROI will remain in eect for two years from the signature date,
or until the indicated expiration date, or if the student revokes it in writing.
Please readAuthorization to Release Information FAQs on back of this form.
STUDENT RELEASE
I, (student) , do hereby waive my rights under the Family Educational Rights
and Privacy Act of 1974 and authorize Columbia Basin College to discuss and/or disclose all my academic records (excluding
my Social Security Number) to the following individual(s). This ROI will expire on
Date
(if expiration date is left blank,
expiration will be two years from the signature date below).
Remember to provide the authorized person with your date of birth, student ID and answer to challenge question.
Clearly print the information below.
Name Relationship to Student Phone
Name Relationship to Student Phone
A challenge question and response are required and will be verified each time the designated person contacts the Registrar or
College designee. You must inform the authorized person of the challenge question and the response that you selected. Samples of
challenge questions: Name of your first pet? Color of your first car? Your favorite subject in high school? Father’s middle name?
Challenge Question
(please limit to 90 characters including spaces)
Challenge Response
(please limit to 30 characters including spaces)
Photo ID (ie: driver’s license) required at the time of form submission.
Student Signature Date
(Must be signed in the presence of a Hawk Central employee.)
Columbia Basin College complies with the spirit and letter of state and federal laws, regulations and executive orders pertaining to civil rights, Title IX, equal opportunity and armative action. CBC does not discriminate on the basis of race,
color, creed, religion, national or ethnic origin, parental status or families with children, marital status, sex (gender), sexual orientation, gender identity or expression, age, genetic information, honorably discharged veteran or military status, or
the presence of any sensory, mental, or physical disability, or the use of a trained dog guide or service animal (allowed by law) by a person with a disability, or any other prohibited basis in its educational programs or employment. Questions
or complaints may be referred to the Vice President for Human Resources & Legal Aairs and CBC’s Title IX/EEO Coordinator at (509) 542-5548.Individuals with disabilities are encouraged to participate in all college sponsored events and
programs. If you have a disability, and require an accommodation, please contact the CBC Resource Center at (509) 542-4412 or the Washington Relay Service at 711 or 1-800-833-6384. This notice is available in alternative media by request.
click to sign
signature
click to edit
Authorization to Release Information FAQs
Why should I sign this release?
Circumstances often arise where a student may want a parent, relative, or another individual to discuss with the Registrar, or
College designee, information regarding their academic records. The Registrar, or College designee, will accept a Release of
Information from a student consenting to release information from their academic records to an individual named by the student.
Please note that the Release of Information does not allow the authorized person to initiate or complete transactions or serve as a
representative on their behalf.
What are academic records?
Academic records are records that contain information that is directly related to a student. Academic records are maintained by
an education agency or institution or by a party acting for the agency or institution. Academic records may include, but are not
limited to, advising file notes, CBC transcripts, Financial Aid information, scholarship awards, class schedules, student account/
billing information, student employment related information, class attendance, class progress reports/information, grades,
placement scores, disability services records, etc. Please note that personal counseling records are not covered under the FERPA
rules and a separate release form must be obtained from the Counselor of record.
How do I implement the release?
Bring the completed release form and your photo ID (i.e.: driver’s license) to the Hawk Central oce during normal business
hours. The release must be signed in the presence of a Hawk Central employee. A challenge question and response must be
completed so that sta can verify each time the authorized person requests information. You must inform the authorized person
of the challenge question and the response that you selected.
How will the release be used?
Once the release has been received, the individual(s) listed may call or visit the Registrar, or College designee, to ask questions
regarding your academic records. The individual must inform the Registrar, or College designee, that a release form is on file. Prior
to releasing any information, the Registrar, or College designee, will verify with the individual their name, the student’s date of
birth, student’s identification or social security number, and the answer to the challenge question.
May I rescind this release?
The Release of Information will remain in eect for two years from the signature date, or until the indicated expiration date, or if
the student revokes it in writing. To rescind this release, please send a written statement to Student Records that includes your:
Full name
Date of birth
Student ID
Statement to rescind the request (please include an eective date)
Name of the individual who no longer will have access to your educational records
Signature and date
Where do I submit this release?
Please return in person with your photo ID (ie: driver’s license) to:
H Building, Hawk Central
Pasco Campus
What if I have additional questions?
Sta is available to answer your questions during normal business hours. Hawk Central is located in the H building of the
Columbia Basin College Pasco campus.
Revised 8/2019
We are temporarily unable to accept this form 'In Person' while our campuses operate
remotely. Please submit the completed form and a copy of your photo ID (eg. driver's license)
from your CBC student email to records@columbiabasin.edu.
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