Student Release Form

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Grant Funded Student’s Authorization
to Disclose Information from Education Records
I understand that my educational records are protected by the Family Educational Rights and Privacy Act of 1974, and they may not be disclosed without my prior
written consent. I hereby consent to the disclosure of the following education records pertaining to me to the persons and for the purposes as stated below:
I hereby authorize the following officials:
1.
Waubonsee Community College (WCC) officials and faculty members teaching courses in which I am currently (or was) enrolled
2.
Illinois Community College Board (ICCB); Department of Labor; Kane County Department of Employment & Education (KCDEE); Research, Evaluation,
and Policy Studies of Northern Illinois University (REPS); and Illinois Department of Employment Security (IDES).
to disclose the following:
1.
demographic or contact information, which may include social security number and other personally identifiable information
2.
employment status
3.
financial information including but not limited to financial aid, employment pay stubs, and Veterans benefits
4.
academic records including, but not limited to placement test results, class schedule, interim and final grades, attendance, and any information
regarding my academic progress prior to the final determination of grade
5.
case notes written by WCC officials
6.
achievements or credentials achieved including, but not limited to GED completion, further enrollment in college credit courses, advancement in
employment, obtain employment, earned credentials, and course completion
to the following persons:
1.
ICCB, Department of Labor, KCDEE, REPS, and IDES
2.
Specific state and federal grant funders, lead agencies, fiscal administrators of grant programs
3.
WCC college officials with a legitimate educational need to know
for the following purposes:
1.
to monitor, assist and determine eligibility for grant-funded programs
2.
to monitor and assist with respect to retention and student support needs
3.
for reporting requirements of specific grant programs; as well as for statistical analysis of grant outcomes
4.
to monitor and assist with graduate placement needs and employment outcome tracking
I understand further that:
1.
such records may be disclosed only on the condition that the party to whom the information is disclosed will not re-disclose the information to any other
party without my written consent unless specifically allowed by law.
2.
I have the right to not consent to the release of my educational records for these purposes only by initialing the box below.
3.
this authorization remains in effect unless revoked by me in writing.
A copy of this authorization shall be considered as effective and valid as the original.
By signing below, I certify that I agree to the disclosure of the records referenced above. This authorization and consent by me is valid for the life of the grant
reporting period or until I revoke it in writing.
PRINTED NAME
STUDENT X#
STUDENT SIGNATURE
DATE
By checking the box to the left and signing below, I do not authorize the disclosure of my information and understand that I may not be eligible to receive grant-
funded educational assistance because of this decision.
PRINTED NAME
STUDENT X#
STUDENT SIGNATURE
DATE

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