Student Authorization to Release Information
(This form is to be completed and submitted by the student only; valid photo ID required.)
Request to release personally identifiable and confidential information: The Family Educational Rights and Privacy Act (FERPA)
requires the Admissions & Records, Counseling, Financial Aid and Learning Assistance Program offices to release detailed information to
the student, only. The student may authorize the release of certain information by completing this form.
Please print using blue or black ink:
AHC Student ID Number: H ____________________________ Date: __________________________
Student’s Full Name: _____________________________ _____________________________ ______
Last Name First Name MI
I hereby give permission to Allan Hancock College Student Services personnel, consistent with the FERPA act of 1974, to discuss or
release the selected information (please check all that apply):
Admissions Information:
□ Fees and Tuition
□ Grades
□ Holds
□ Official Transcripts
□ Schedule of Classes
□ Unofficial Transcripts
□ Username and Password for myHancock
(access to most student information via the portal)
□ Verification of Enrollment Letter
Financial Aid Information:
□ Award Amount
□ Dependency Status
□ Financial Aid Appeals
□ Financial Aid Status
□ Income Tax Forms
□ Loan Disbursement
□ Payment Disbursement
□ Satisfactory Academic Progress
Counseling Information:
□ Academic Advising
□ E-Advising
□ Phone Advising
□ START Results
□ Student Discipline
Veterans Information:
□ Educational Certification Status
List any additional information to release: __________________________________________________________
If you, the student, are requesting information via the telephone, you must write YOUR name and write SELF on the relationship
line. If you are also releasing the information to a third party, you may list additional names.
This information may be released to: ______________________________ ________________________________
Full Name Relationship to Student
This information may be released to: ______________________________ ________________________________
Full Name Relationship to Student
This information may be released to: ______________________________ ________________________________
Full Name Relationship to Student
To secure your information, please provide answers to the student identifiers on the reverse side of this form. Please share these identifiers
with your authorized person as they will be asked these questions when inquiring about your information.
I understand that the permission(s) checked above will remain in effect until I revoke them in writing. In the event damages should occur
due to the release of such information, I agree to hold Allan Hancock College harmless.
Student Signature (mandatory): _______________________________________________ Phone number: __________________
In addition to this completed form, if the student is mailing, or emailing this form, a copy of the student’s government issued photo
identification must be attached.
For office use only:
The signature below, verifies that Student Services staff member has viewed the student’s photo identification (AHC Photo ID, or
Government Issued ID Card) and has accepted the form from the student.
_______________________________________ ___________________________________________________
AHC Staff Member Printed Name AHC Staff Member Signature and Date
To maintain access to student services departments and to permit scanning and indexing, completed forms must be submitted to the
Admissions and Records office.
click to sign
signature
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