Fillable Release of Student Information (Modesto Junior College)

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Release of Student Information (Modesto Junior College)

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The Release of Student Information (Modesto Junior College) form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Modesto Junior College

BROWSE MODESTO JUNIOR COLLEGE FORMS

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MJC Enrollment Services Phone (209)575-6853
EAST 435 College Avenue, Student Services Bldg. 1st Floor WEST 2201 Blue Gum Ave, Yosemite Hall 1st Floor
Request to release personally identiable and condential information: The Family Educational Rights and Privacy Act (FERPA)
requires the Enrollment Services and Student Financial Services oces to release detailed information to the student, only. The
student may authorize the release of certain information by completing this form.
The Release of Student Information Form must be submitted with proper identication of both the student and parent/
guardian in which information is being released to.
Today’s Date:
Student Information
First Name: Middle Initial: Last Name:
Student ID: w Birthdate: Phone:
I hereby give permission to Modesto Junior College Student Services personnel, consistent with the FERPA act of 1974, to discuss or
release the selected information (please check all that apply):
Admissons Information: Financial Aid Information:
Fees and Tuition Award Amount
Grades Dependency Status
Holds Financial Aid Appeals
Ocial Transcript Financial Aid Status
Schedule of Classes Income Tax Forms
Unocial Transcript Payment Disbursement
Verication of Enrollment Letter Satisfactory Academic Progress
This information may be released to:
This information may be released to:
This information may be released to:
I understand that the permission(s) checked above will remain in eect until I revoke them in writing. In the event damages should occur due to
the release of such information, I agree to hold Modesto Junior College harmless.
Student Signature: Date:
10/2019_SJB
Release of Student Information
Submit completed form in-person to Enrollment Services or
Student Financial Services with photo identication.
OFFICE USE ONLY
Comments:
UTEC Sta Initials: Date:
Full Name
Full name Relationship to Student
Relationship to Student
Full name Relationship to Student
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Release of Student Information (Modesto Junior College)

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Completed 4 September 2020

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