AUTHORIZATION TO RELEASE INFORMATION
The Family Education Rights and Privacy Act (FERPA) of 1974 is designated to protect the privacy of educational records, to establish the rights of students to inspect and review the educational records, and to provide guidelines for the correction of inaccurate or misleading data through informal and formal hearings. Muskegon Community College’s procedures for complying with the provisions of this Act can be found in the college catalog or on the web at www.muskegoncc.edu. In accordance with FERPA, the College may not discuss your academic and/or financial information with your parents, spouse, or guardian. You should give great consideration to this before choosing to exercise this option and submitting this form.
STUDENT NAME
*
First Name
Last Name
MCC ID NUMBER
*
XXXXXXX
MCC EMAIL ADDRESS
*
janedoe@muskegoncc.edu
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
STUDENT AUTHORIZATION: (Check all that apply) By checking the box(es) you agree you have read this document and fully understand the contents. You agree to release all information checked below:
*
College Transcripts/Grades/Academic Standing
Financial Aid Awards and History
Student Accounts/Billing Information
Class Attendance
Student Conduct and Discipline
Other
If Other Please Specify
RELEASE INFORMATION TO
Multiple spaces provided for multiple individuals (NOTE: PIN created will be the same for all)
Name of individual to release information
*
First Name
Last Name
Relationship to student
*
Name of individual to release information
First Name
Last Name
Relationship to student
Name of individual to release information
First Name
Last Name
Relationship to student
STUDENT CREATED *PIN REQUIRED
*
This number must be 4 digits (ONLY NUMBERS)
ID UPLOAD
*
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Authorization Statement
By completing and signing this form, you authorize Muskegon Community College to discuss your information with your designee(parent, spouse, partner, relative, guardian, etc.). The student is required to submit a *PIN Number below and the designee must confirm the PIN # with College Staff before information can be released. You should know that by signing this form, College personnel may disclose any information pertaining to your records that you have authorized. This authorization will remain in effect until you submit a “Retraction of Authorization to Release Information” Form terminating this consent to the Muskegon Community College’s Student Welcome Center in the Student Center.
Student Signature
*
By signing, you authorize Muskegon Community College to release your selected records to the individual(s) listed, and this consent will remain in effect until you submit a written FERPA authorization revocation.
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