Authorization for Release of Information

Release of Information

This form is utilized for authorizing the release of your records to any party other than yourself.

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Your full name:

Your Information

Please enter your information below.

Only your information is required - do not add additional persons to this appeal request. Appeals must be requested on an individual basis.

Name

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

Please answer the following questions.

I, the individual indicated above, authorize the Office of Student Conduct and/or Office of Student Affairs to release the following information:(Required)

Any and all of my student conduct records Only my records associated with a specific incident All of the following information/records

This field is required.

If you selected only records associated with a specific incident, please indicate the case number below.(Required) This field is required.

If you selected all of the following information/records, please indicate which records you would like us to release below. This field is required.

Please indicate below the dates for which this authorization of release is valid for using DD/MM/YY formatting. (E.g. 2/11/13 until 3/15/13)(Required) This field is required.

I permit the above listed information to be released to and/or discussed with the persons and/or agencies listed below. (Please be specific and list all names and/or agencies.)(Required) This field is required.

Release of Information

Your Information

Questions

Submission