Fillable Release-of-records Student Consent For Release Of Records (South Puget Sound Community College)

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Release-of-records Student Consent For Release Of Records (South Puget Sound Community College)

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The Release-of-records Student Consent For Release Of Records (South Puget Sound Community College) form is 1 page long and contains:

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  • 14 check-boxes
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File type: PDF

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Enrollment Services / Student Financial Services
2011 Mottman Rd SW | Olympia, WA 98512
enroll@spscc.edu
STUDENT CONSENT FOR RELEASE OF RECORDS
For Staff Use Only
Scanned
Date
Initials
Enrollment
Financial Aid
1. Students are expected to monitor their my.spscc.edu email account, which is the primary method the college will use to communicate with
students. The College may release requested information via that email address without a release form. To release information to others,
this form must be submitted in person to the One-Stop on the Olympia or Lacey Campus or from the student’s my.spscc.edu account. If
not submitted by the student, the form must include a copy of the student’s valid photo identification including signature.
2. Any other release forms sent directly from an outside organization or third-party must be on agency letterhead or be a court document, and
include student signature.
3. This is not an official transcript release form. By completing this form, the student is allowing their academic and/or financial records
(unofficial transcripts, test scores, schedules, and/or financial aid data) to be released to someone other than himself/herself.
Student Last Name
Student First Name
SID
Social Security Number
Street Address
Apt #
City
Zip Code
Phone Number
Email Address
Under federal legislation, The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99), I understand that my
educational records cannot be released without my written permission or a Parental Affidavit of Dependency certified by my parent or
guardian. I, therefore, request that the information listed below be released to the following individual(s):
Name of Recipient(s)
Street Address
Apt #
City
State
Zip Code
Check the boxes below to indicate the information that you consent to be released and check the boxes to indicate the methods by which the
information may be released. If not specified, information will only be released in person. Please note that Financial Aid information will not
be released via email.
Department
Types of Records
Methods of Release
Required Information
Enrollment
Services
☐ Grades/Unofficial Transcript
☐ Schedule (Information Only)
☐ Allow Others to Change My
Schedule
☐ In Person (with Photo ID)
☐ By Phone (specify number)
Specify phone number below
☐ By Email (specify email address)
Specify email address below
Cashiering
Services
☐ Account Balance (tuition, fines, etc.)
and Make Payments on My Behalf
☐ In Person (with Photo ID)
Student
Financial
Services
☐ Financial Aid Information
☐ In Person (with Photo ID)
Specify recipient’s phone password below
(should not be the same as your password)
☐ By Phone (Password Required)
Faculty
☐ Class Information (assignments,
grades, attendance, etc.)
☐ In Person (with Photo ID)
☐ By Email (specify email address)
Specify email address below
Expiration Date
Indicate an expiration date. If the expiration date is left blank, the permission will
expire on June 30
th
of the calendar year following the date the release was signed.
Student Signature
Today’s Date
Revised: 10-16-19
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Release-of-records Student Consent For Release Of Records (South Puget Sound Community College)

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Completed 25 July 2020

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