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INFORMED CONSENT/AUTHORIZATION TO RELEASE STUDENT INFORMATION

I,                                                                                   (Student ID #),                          _____

hereby authorize Rochester Community and Technical College to release and/or orally discuss the education records described below about me to: (list complete names of parents or other persons you are authorizing - note that they may be asked for proof of their identity)

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

The specific records covered by this release are (select with checkmark):
____ All
____ Academic (grades and transcripts, academic standing, attendance, etc.)
____ Accounts Receivable (itemized charges or credits)
____ Financial Aid (eligibility, itemized charges, credits, and refunds)
____ Registration (number of credit hours, add/drops)
____ Other - please specify: _________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

I understand that the student records information listed above includes information which is classified as private on me under Minn. Stat. § 13.32 and the Federal Family Education Rights and Privacy Act. I understand that by signing this Informed Consent Form, I am authorizing Rochester Community and Technical College to release to the persons named above information which would otherwise be private and not accessible to them.

I understand that, at my request, Rochester Community and Technical College must provide me with a copy of any written educational records it releases to the persons named above pursuant to this consent. I understand that I am not legally obligated to provide this information and that I may revoke this consent at any time. This consent expires after one year or until I withdraw my consent, whichever comes first. A photocopy of this authorization may be used in the same manner and with the same effect as the original documents.

I am giving this consent freely and voluntarily and I understand the consequences of my giving this consent.

Effective Date: (optional) ___________________________   

Expiration Date: (optional) __________________________

Signed: _______________________________________   

Dated: ________________________________________

Notary or College Staff/Date: ______________________________________________
(notarized signature is required unless the signature is witnessed by college staff upon presentation of photo ID)

 

 

 

Rochester Community and Technical College
851 30th Ave SE, Rochester, MN 55904-4999
Contact Info: (507) 285-7210 or 1-800-247-1296 / TTY Relay 1-800-627-3529
RCTC is a University Center Rochester partner and a member of the MnSCU system.
© 2007 Rochester Community and Technical College, All rights reserved.
RCTC is an affirmative action, equal opportunity educator and employer.
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