Ferpa Authorization To Release Information From Student Education Records Form - Spokane Community College Page 2

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Records are disclosed per your instructions. The Community Colleges of Spokane assumes no
responsibility for the confidentiality of records that are transmitted by fax, e-mail or other delivery methods
for which identification of the recipient cannot be personally verified by a college official.
By signing this form, I authorize Community Colleges of Spokane (CCS) to release and disclose information
from my educational records as specified. This authorization remains in effect as specified or until I revoke
this authorization in writing to the appropriate CCS Registrar’s Office.
Student’s Signature
Date
/
/
Send original completed form to:
SCC Registrar’s Office (MS 2151) Building 15
SFCC Registrar’s Office (MS 3011) Building 17
IEL Registrar’s Office (MS 3027) Magnuson Building 27
FOR OFFICE USE
Date information was released
/
/
By Staff
Date
By
Department
Disclosure Information
As requested by the student noted via
Mail
Fax
US Mail
In person
Information not available (please specify)
Other (please specify)
Recorded in Student Quarterly
Comment Screen (SM4015) on
/
/
By Staff
Date
Scanned in halFile on
/
/
Date
Form completed, signed and dated
Send form to appropriate institution for processing and scanning
FERPA form on file at designated institution
CCS 40-200 (Rev. 06/12)
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