Page 54 - 2016 Iowa Central Student Handbook
P. 54

Iowa Central Community College
                          Release of Information

       This completed and signed Release of Information Form must be on file with Iowa
       Central if students want to share information with parents, guardians, the military, etc.

       I,  ___________________________________________ ,___________________________
                                                          -               -
                        (Student Name)                (Social Security Number)
       and/or _______________________________________ .
                           (Student ID#)
       do hereby authorize Iowa Central Community College to release the follow-
       ing non-directory information (check any that apply):

         r   Financial Aid Information   r   Billing Information
         r   Grades and GPA          r   Class Schedules
         r   Housing Information     r   Class Attendance
         r   Health Information      r   Veteran’s Information
         r   Academic Accomodations

       To: ______________________________________________________________________
                   (relative/facility/agency name - be specific. The term “parents” is not acceptable)

       I understand that the information may be given verbally or in written form and
       this release includes permission to furnish copies.

       I understand that this release agreement is only valid for the school year of
       ___________________ (example 2016-2017).

                        (Signature of Student)                (Date)

                                                                Revised 5/13/2016
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