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Revised July, 2016 - 1 - Academic Year 2020/2021
Please initial all that apply:
__________ All financial records in the Business Office
__________ All Financial Aid Information
__________ All academic records in the Registrar Office
__________ All medical/ disability documents in Student Support Services
_________ Other: ______________________________________________
_________ Other: _____________________________________________
FERPA Consent to Release Student Information
Office of Registrar ∙ Building 3 ∙ 7390 South Sixth Street ∙ Klamath Falls, OR 97603
________________________________ ____________________________ ______________________
Last Name First Name Student ID Number
It is the policy of Klamath Community College, in accordance with the Family Education Rights and Privacy Act (FERPA), to withhold personally identifiable
information contained in our students’ education records unless the student has consented to disclosure. Private information, such as grades, class
schedules, the student’s account, and financial aid awards may not be released without express consent from the student. Signing this form provides such
consent, according to the information designated for release and to whom it is to be released.
I, ______________________________________, authorize Klamath Community College to release the following educational records, upon request, to the
persons listed below, for the purpose of keeping them informed regarding my education at Klamath Community College.
Persons to whom information can be released:
Name: ______________________________________________________________________ Relationship: _______________________________________
Name: ______________________________________________________________________ Relationship: _______________________________________
Name: ______________________________________________________________________ Relationship: _______________________________________
Name: ______________________________________________________________________ Relationship: _______________________________________
All listed persons will have access to the initialed information/ departments above. If a person shall have access to different information than listed, student
must complete a separate form for said person.
Revised July, 2016 - 2 - Academic Year 2020/2021
Name:______________________________________
Mailing Address: _____________________________________________
___________________________________________________________
Phone Number: (______) ___________________________
Email: ___________________________________________
Name:______________________________________
Mailing Address: _____________________________________________
___________________________________________________________
Phone Number: (______) ___________________________
Email: ___________________________________________
Name:______________________________________
Mailing Address: _____________________________________________
___________________________________________________________
Phone Number: (______) ___________________________
Email: ___________________________________________
Name:______________________________________
Mailing Address: _____________________________________________
___________________________________________________________
Phone Number: (______) ___________________________
Email: ___________________________________________
I acknowledge by my signature that I understand that, although I am not required to release my records, I am giving my consent to release the designated
information to the above named person(s). I understand that this release will remain in effect unless I revoke such consent in writing and the revocation is
received and processed by Klamath Community College.
__________________________________________________________________ ______________________________________
Student Signature Date
Please provide the contact information for the previously stated persons to whom information can be released.
Office Use Only:
Received By: __________________ Date: _______________
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Completed 3 October 2020

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