Student Academic Records Release Form

Student Academic Records Release Form
Please complete this form to authorize the release of your academic records.
Student Full Name
First NameLast Name
Student Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student ID Number
Institution Name
Recipient Name or Organization
Recipient Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Reason for Release
Signature of Student or Legal Guardian
Clear
Date of Signature
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: