Consent_To_Release_Student’s_Information

Consent to Release Students Information

"*" indicates required fields

All information pertaining to this document is confidential. Casa College will not disclose other than “directory information” about students to people outside the College unless the student has given written consent or in certain other cases permitted by law and College policy. You may choose to grant the College the right to disclose education records to certain individuals in accordance with the College policy by completing and submitting this consent form. You have the right to revoke this consent at any time. Fill in your details in BLOCK CAPITALS only.

File No. :

Application Date :*

PEOPLE TO WHOM CASA COLLEGE IS AUTHORISED TO RELEASE ACADEMIC RECORDS AND OTHER INFORMATION

Please provide information up to two (2) people

Person 1 Information:

First Name:*

Middle Name:

If you do not have a Middle name, please write N/A.

Last Name:

If you do not have a Last name, please write N/A.

Relationship Status:*

Example: Father,Mother,Brother, etc.

Phone including the country code:*

Email:*

Address*

Street Address City ZIP / Postal Code Country

Person 2 Information:

First Name:*

Middle Name:

If you do not have a Middle name, please write N/A.

Last Name:

If you do not have a Last name, please write N/A.

Relationship Status*

Example: Father, Mother, Brother, etc.

Phone including the country code:*

Email:*

Address*

Street Address City ZIP / Postal Code Country

Please specify what type of information we can provide:

Attendance

Midterm Exam's Results

Final Exam's Results

Retake Exam's Results

Medical Problems

Other

In case you selected "Other" please specify:

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