UNIVERSITY OF ILLINOIS AT SPRINGFIELD
Office of Records and Registration Authorization of Grade Disclosure
Please complete, print (see "Print Form" button above), sign, and return this form to the Office of Records and Registration, University Hall, One
University Plaza, MS UHB 1076, Springfield, IL 62703-5407. Forms are processed on a weekly basis. Please be sure to carefully complete all
information prior to printing the document.
Last Name First Name
UIN
Permanent Address
City State Zip Code
Records (217) 206-6709 Degree Audits (217) 206-8216 Registration (217) 206-6174 Graduation (217) 206-7730
For Office Use Only
Processed By:
Date:
Student Signature
I hereby authorize the University of Illinois at Springfield to release my grade information to the parent(s) and/or guardian(s) listed below. Please
note the following:
1. This release will remain in effect until the student listed above notifies the Office of Records and Registration that this grade disclosure is no
longer valid.
2. "Grade information" refers to academic information as seen on a University grade report or unofficial academic transcript.
Parent/Guardian Last Name
Parent/Guardian First Name
*Address for second parent/guardian (if different from above):
*Parent/Guardian Last Name *Parent/Guardian First Name
Permanent Address
City State Zip Code
I understand that by signing this authorization, I am waiving my rights of nondisclosure of these records under federal law only as to the person(s)
specifically listed. This release does not permit the disclosure of these records to any other persons or entities without my written consent. This
release will remain in effect until I provide written notice to the Office of Records and Registration to withhold grade information.
Date
Copies (distributed by the Office of Records and Registration):
Original:
Student Registrar
Permanent File
