STARI
STUDENT AUTHORIZATION TO RELEASE INFORMATION
(2018-2019 Academic Year)
2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4219 FAX: 928-226-4110 finaid@coconino.edu
FA-107-STARI 20171127
This form will be accepted in person only, the student must provide a photo ID. A copy of your photo ID will be
made by the College Official accepting your form. This form will NOT
be accepted from anyone other than the
student. This form will NOT be accepted by fax or email.
I, , hereby give my consent to Coconino
Student Name – Print clearly
Community College to release non-directory information to:
Parent:
Parent:
Spouse:
Other:
Other:
This consent is limited to the following information:
Admission status
Attendance
Billing
Course / Enrollment Schedule
Financial Aid status / Awards
Grade / Academic Transcript
No limitation- share anything and everything
Other:
I understand this consent to be in effect until I submit written notification to Coconino Community
College of cancellation.
Student Signature Date
This Section Completed by a College Official
The above named student has appeared before me and signed this document verifying his/her identity. I have made a
copy of their photo identification and attached it to this form.
Date:
Campus Location: Lone Tree; 4
th
CCC ID# Last Name First Name MI
Mailing Address City ST Zip Code
Telephone No. (include area code) Email Address
