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Release of Information Form

I, ________________________________________________, the undersigned, hereby authorize the following individual, agency, institution or organization, Canyon College (Records Custodian), to release and provide to:

Name: ___________________________________________________________________________________

Address: ________________________________________________________________________________

Fax: ( ______ ) ________ - _______________ with copies of documents as may be listed below. I acknowledge that I understand the purpose of the request and that authorization is hereby granted voluntarily.

Student Information:

Student Name (Last, First, Middle): _____________________________________________________

Address: ________________________________________________________________________________

Phone: ( ______ ) ______ - ___________ Date of Birth (mm/dd/yy): ______ / ______ / ______

Requested Information or Documents:

[ ] Student academic report
[ ] Student enrollment status
[ ] Other (Please explain in detail): ________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

NOTE: I understand that this release is valid for a period of one hundred and twenty (120) days. I further understand that I may cancel or revoke this authorization at any time in writing.

Dated this _____________ day of ______________________________________, ________________

By my signature below, I consent to the release of the above listed information / documents.

Printed Name of Student: _______________________________________________________________

Signature of Student: __________________________________________________________________