Last name First name
Phone
I
give permission to American Language Center to release the following educational records
and the selected information to the recipient listed below for the purpose of
Name Description
This release is one time release.
All records listed below
Academic information, transcript, grades received, attendance information, warnings, TOEFL Test results
Student information release form
Check all that apply:
Includes balance, tuition and fees, collection and dept information, due dates, sponsorship information.
Student's enrollment dates, length of study, status of the application, program selected, admission status
__________________________________________________________________________________
Please complete the FERPA Release Form and submit to Admissions/Administrative Office.
Includes student's name, phone number, e-mail, address, date of birth
All records
Financial Information
Academic records
Personal information
Registration/Admission
Other
This release is one time release.
Cancel previous request
Name Phone Organization (if applicable)
Name Phone Organization (if applicable)
Date
OFFICE USE ONLY
Verified by ____________________________________
Must be notarized, unless the student is submitting the form in person
with a valid photo ID
Persons to whom information may be released:
Signature of Student
I acknowledge by my signature that I understand although I am not required to release my records, I am giving my consent to
release the information. I understand that this release remains in effect unless I revoke such consent in writing and the
revocation is delivered to the institution.
This release will remain in effect while enrolled unless I revoke such consent in writing.
All records
Financial Information
Academic records
Personal information
Registration/Admission
Other