Release of Personal Information (Outside Parties)

Release of Personal Information to Outside Parties

I understand that no provate information of any kind concerning any student will be released without specific written permission by the student.

Authorization valid until September of the next academic year.

For IBOLT students, this authorization it valid for the duration of their studies/program.

_________________________________________________________________________________________

First Name: *

Middle Name:

Last Name: *

Student ID Number: *

____________________________________________________________

Outside Parties are defined as:

Financial - This includes my outstanding balance, account history and payment information including a T2202A.

Grades - This included academic standing. Please note that in some cases you may be required to complete a Transcript Request Form.

Registration - This includes program and year of study, as well as current and historical course work.

______________________________________________________________________________________

I am authorizing the release of specific information as indicated below: *

Yes

No, I do not authorize the release of my financial information, grades, or registration to any other person or entity.

Authorization #1 - First and Last Name of the person(s) you wish to authorize: *

Authorized to receive: *

Financial

Grades

Registration

Authorization #2 - First and Last Name of the person(s) you wish to authorize:

Authorized to receive:

Financial

Grades

Registration

Authorization #3 - First and Last Name of the person(s) you wish to authorize:

Authorized to receive:

Financial

Grades

Registration

Authorization #4 - First and Last Name of the person(s) you wish to authorize:

Authorized to receive:

Financial

Grades

Registration

Student Signature: *

Date: *