Fill - Free fillable Releaseof Information Form Interactive 1 (Minnesota State Community and Technical College) PDF form

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RELEASE OF INFORMATION FORM www.minnesota.edu I 877.450.3322

CONCURRENT ENROLLMENT PROGRAM 

TOWHOMITMAYCONCERN:

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I,_____________________________________,(studentID#)_________________,herebyauthorizeMinnesotaState

CommunityandTechnicalCollegeand(highschoolname)_________________________________________________

toreleaseand/ororallydiscusstheeducaonrecordsdescribedbelowaboutmeto:

Name (

Listnamesofbothparents,guardiansandothers) RelaƟonship

_______________________________________________________________________________________________

_______________________________________________________________________________________________



Thespeciﬁcrecordscoveredbythisreleaseare(checkallthatapply):



_____RegistraƟon(add/drops/wit hdrawals) 

_____Grade Reports

_____Classroom AƩendance/Academic Progress/Performance/Behavior

_____All of the above

_____Other (pleasespecify)____________________________________________________________________



Iunderstandthatthestudentrecordsinformaonlistedaboveincludesinformaonaboutmewhichisclassiﬁedas

privateunderMinn.Stat.§13.32andtheFederalFamilyEducaonRightsandPrivacyAct.Iunderstan

dthatbysigning

thisInformedConsentForm,IamauthorizingMinnesotaStateCommunityandTechnicalCollegeandmyhighschoolto

releasetothepersonsnamedaboveandtheirrepresentave’sinformaonwhichwouldotherwisebeprivateandnot

accessibletothem.



Iunderstandthat,atmyre quest,MinnesotaStateCommu

nityandTechnicalCollegeandmyhighschoolmustprovide

mewithacopyofanyeducaonalrecordsitreleasestothepersonsnamedabovepursuanttothisconsent.I

understandthatIamnotlegallyobligatedtoprovidethisinformaonandthatImayrevokethisconse

ntatanyme.

This consent expires one year from the date signed or unƟl I withdraw my consent, whichever comes ﬁrst.A

photocopyofthisauthorizaonformmaybeusedinthesamemannerandwiththesameeﬀectastheoriginal

document.



IamgivingthisconsentfreelyandvoluntarilyandIunderstandtheconsequences ofmygivingthisconsent.



NamePrinted:__

___________________________________________



Signature:_________________________________________________Date:_______________________



The college is asking you to provide informaƟon which includes private informaƟon under State and Federal Law. The informaƟon is opƟonal;

however, if you refuse to provide some or all of the opƟonal informaƟon, the college may not be able to process your request.

Please keep this completed form with the student’s record at the high school.

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Releaseof Information Form Interactive 1 (Minnesota State Community and Technical College)

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