Release of Information FormI, ________________________________________________, 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: __________________________________________________________________ |