Student Information Release
Authorization
In complianc
e with the federal Family Educational Rights and Privacy Act of 1974, the College is prohibited from disclosing
certain information in your education record, such as grades, billing, tuition and fees assessments, financial aid (including
scholarships, grants, work-study, or loan amounts) to a third party without your prior consent. This restriction applies, but is
not limited to, your parents, your spouse, or sponsor.
You may, at your discretion, grant the College permission to release information from your education records to a third party
by submitting a completed Student Information Release Authorization form. You must complete a separate form for each
third party to whom you wish to grant access to your education record information. The specified information will be made
available only upon request by the authorized third party.
Student Information:
__________________ __
Last Name First name Student ID#
__________________ __
Current Address (Street/PO, Apt) City State Zip Code
Third Party Designee:
_______________________________________________________________________
Organization Name (If applicable) Last Name First Name
____________________
Current Address (Street/PO, Apt) City State Zip Code
Education record information to be released: (Check one or more below to grant authorization)
Official or unofficial college transcript
Billing statements, charges, credits, payments, past due amounts, and/or collection activity
Financial aid awards, application data, disbursements, eligibility, and/or financial aid satisfactory academic progress
Access to student records maintained by the Academic Records Office, Student Payment, and Financial Aid, including all of the above
examples
Other, please specify: ___________________________________________________________________________
Return the completed form:
Email via your BHCC email account to:
academicservices@bhcc.edu
Note: You may revoke your authorization at any time by sending a written request to the address above.
BHCC ID: _________________________________
Student Signature: __________________________________________________ Date: ____________
