Release Of Information Form - San Mateo County
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1
2RELEASE OF INFORMATION
Check Appropriate College
Admissions
Admissions
Admissions
Cañada College
College of San Mateo
Skyline College
4200 Farm Hill Boulevard
1700 West Hillsdale Blvd.
3300 College Drive
Redwood City, CA 94061
San Mateo, CA 94402
San Bruno, CA 94066
Phone: (650) 306-3226
Phone: (650) 574-6165
Phone: (650) 738-4251
SMCCCD
Fax: (650) 306-3113
Fax: (650) 574-6506
Fax: (650) 738-4200
Student's ID# G:_____________________
Last Name __________________________ First Name ____________________ Middle ________________
Mailing Address:___________________________________________________________________________
Phone Number:__________________________________ Email:____________________________________
I have read the following FERPA (Family Education Rights & Privacy Act) information on page #2 and request:
Student:
To release my Educational Records to the following person or agency:
Name of person or agency: _____________________________________
That the school not disclose directory information and I understand
that this request expires after the academic year and that I must make this request
every academic year.
STUDENT SIGNATURE_________________________________________DATE:_____________________
OR
Parent/Guardian:
• I wish to obtain the academic records of student listed above
• Student is my legal dependent
• I have supplied documentation of dependency (IRS Tax Form)
I understand that this release is only valid for the academic year, and that my permission may be cancelled or
revoked at any time by providing an updated/written statement.
PARENT/GUARDIAN SIGNATURE_______________________________DATE:_____________________
ADMISSIONS AND RECORDS OFFICE
Processed by: _______________________________________ Date: _________________________________
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