STUDENT AUTHORIZATION TO RELEASE INFORMATION
(2020-2021 Academic Year)
2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4219 FAX: 928-226-4110 firstname.lastname@example.org
Students must provide a scan or photo of their state issued photo ID with this form. This form will only be
accepted through CCC’s Secure Upload and in person.
This consent is limited to the following information:
Registration and Enrollment Services (RES)
• Admission status
• Course / Enrollment
Grades / Academic Transcript
Financial Aid Status (FA)
• File Status
Business Administration (BA)
• All information
I give my consent to release non-directory information to those individuals listed on this form. I understand that
this consent is in effect until I submit written notification to Coconino Community College of cancellation. I
hereby provide consent for the use of electronic records and signatures on all financial aid documents. I
understand that if I choose to sign electronically, my electronic signature constitutes a binding contract and
may not be denied legal effect, validity, or enforceability solely because it is in electronic form or because an
electronic signature or electronic record was used in its formation.
Student Signature and Date
How do I create a digital signature with Adobe?
This Section Completed by a College Official
The student signing this form has provided the required state issued photo ID verifying his/her identity.
Campus Location: Lone Tree; 4
CCC ID# Last Name First Name MI
Mailing Address City ST Zip Code
Telephone No. (include area code)
CCC Student Email Address
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