Page 1 of 1 Form no. 04629 CS-EDU Rev. 5/2019
Student Authorization for Disclosure of Information
In Education Records
Pursuant to Family Educational Rights and Privacy Act of 1974, as amended
To authorize the Chickasaw Nation Higher Education Program to obtain your educational information and to authorize the Chickasaw
Nation Higher Education Program to release your educational information to individuals or the college/university you are attending
1) Fill out all appropriate fields on this form; and
2) Hand-deliver or mail the form to the address to the right.
3) Note: Forms will not be accepted without a signature.
First name:
Middle name:
Last name:
Birth date:
Please enter the name of the organization(s) or individuals to whom the authorization is given or revoked. You may enter more than one
name. Enter only ONE name per space.
Organization authorized
given revoked
given revoked
given □ revoked
given □ revoked
Individual authorized
Birth date
given □ revoked
given □ revoked
given □ revoked
given □ revoked
I hereby authorize the to disclose my educational record(s) to the above-mentioned organization or individuals
and also authorize to disclose or obtain my educational record(s) to/from
Student’s signature Date
Parent/legal guardian signature (if applicable)
To enhance security measures, students now have the option to generate a PIN for their student files. Anyone seeking information regarding your student file will be required to verify the PIN before information
will be released. This can be done by going to and clicking on “fill form out online.” By initialing the line below you are refusing this service and allowing organizations/individuals to
retrieve information regarding your file based solely on this form.
Student’s Initials
The vision of the education services department is to provide services that encourage and support academic and professional development of Chickasaw students.
Bill Anoatubby
The Chickasaw Nation
Higher Education Program
300 Rosedale Road
Ada, Oklahoma 74820
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