Information Release Form - Broome Community College printable pdf download

Information Release Form - Broome Community College

Information Release Form

To:

Office of the Registrar

SUNY Broome Community College

PO Box 1017

Binghamton, NY 13902

Date: _______________________________________________________

Semester: ___________________________________________________

Student Name: _______________________________________________

Broome I.D. #: ________________________________________________

Student Address: ___________________________________________________________________

___________________________________________________________________

RE: Release of Information

I hereby authorize the Office of the Registrar at SUNY Broome Community College to release the following non-directory

information pertaining to my student records (Check all that apply):

___Academic Information

___Financial Information

___Medical Information

Person(s) the information may be released to:____________________________________________________________

Code Word:____________________________________

This information will be used for the following reason(s): ____________________________________________________

_________________________________________________________________________________________________

________________________________________________

________________________________

Student Signature

Date

Information Release Form - Broome Community College