Student Information Release Authorization

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In compliance with the federal Family Educational Rights and Privacy Act of 1974 and the Regents’ on Access to and Release of Student Education Records, the College is prohibited from providing certain information from your student records to a third party, such as information on grades, billing, tuition and fees assessments, Financial Aid (Including Scholarships, Grants, Work-Study, or loan amounts) and other student record information. This restriction applies, but is not limited, to your parents, your spouse, or a sponsor. You may, at your discretion, grant the College permission to release information about your student records to a third party by submitting this form. You must complete a separate for each third party to whom you grant access to information on your student records. The specified information will be available only if requested by the authorized third party. The College does not automatically send information to a third party. Submit your completed form to the Admissions and Records Office, Imperial Valley College, 380 E. Aten Road, Imperial, CA 92251. Please note that your authorization to release information has no expiration date; however, you make revoke your authorization at any time by sending a written request to the same address. This form allows third parties to access student record information from Imperial Valley College. NOTE: For the thirds party designee you name on this form, this release overrides all FERPA directory suppression information that you have set up in your student record. However, it is Imperial Valley College policy not to release certain aspects of student records (e.g. registration, grades, GPA) over the phone or via e-mail. This information release authorization is intended for use only by the offices listed below: Admissions and Records Financial Aid Administrative Services
I read and understand the information above.

I read and understand the information above. I understand
A. Student Information
Full Name: Full Name: First Middle Last
Student ID# G00:
IVC Email:
Contact Number: Contact Number: - ### - ### ####
Address: Address:
Street Address City State / Province / Region Postal / Zip Code Country
Upload your IVC Student ID or a Valid ID for verification:

Attach Files
B. Information Types Allowed
Check one or more of the following boxes to Grant Authorization:

Check one or more of the following boxes to Grant Authorization: Current Enrollment. Billing statements, charges, credits, payments, past due amounts, and/or collection activity. Financial aid awards, application data, disbursements, eligibility, and/or financial aid satisfactory academic progress. Access to student records maintained by the Office of the Registrar and the Financial Aid Office, including all of the above examples.
SNAPSHOT Profile of myself:

SNAPSHOT Profile of myself: I understand that only I can request this information and cannot be provided to a 3rd party regardless of any other release of information:
C. Third-Party Designee
Full Name: Full Name: First Middle Last
Program/Office/Agency:
Address Address
Street Address City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Relationship to Student:
Email Address:
Student Signature:

Draw or Type

I understand this is a legal representation of my signature.
Use mouse to sign. Clear

Full Name

I understand this is a legal representation of my signature.
Use mouse to sign.

Student Information Release Authorization

Student Information Release Authorization

A. Student Information

B. Information Types Allowed

C. Third-Party Designee