Student Educational Records Release Consent

Student Full Name Student ID Number Date of Birth

Institution Name Institution Address

Recipient Name (Person/Organization to Release Records To) Recipient Address

Type of Records to Release Academic Transcript
Enrollment Verification
Disciplinary Records
Other (please specify)

Purpose of Disclosure

Authorization Statement

I hereby authorize the above-named institution to release my educational records to the specified recipient for the stated purpose. I understand this consent is voluntary and can be revoked at any time in writing.

Student Signature

Date