Release Of Information Permission Form printable pdf download

Release Of Information Permission Form

Release of Information Permission Form

September 1, 2015- August 31, 2016

Acadia students: The information that Acadia University collects during your time as a student is confidential and is not available

beyond the campus community without your consent. (Please see Release of Information about Students in the Academic Policy and

Regulations section of the Academic Calendar -

)

However, you are able to provide access to this information to others should you choose.

Consent:

Under sections 26(b) and 27(b) of the Freedom of Information and Protection of Privacy Act, I herby grant permission to Acadia University

to release the specified information to the person named below.

This form should be submitted to the Registrar’s Office. If submitting by email, the form should emailed to

registrar@acadiau.ca

through your Acadia University email account.

The person indicated below may have access to:

___ All Information: (Academic, Financial, Scholarship Financial Aid, Counselling, Judicial, Residence Life, and Medical)

The person indicated below may have access to only the information specified below.

___ Academic Information - Current Registration and Course Grades

___ Student Accounts and Financial Information - Current Fees and Payments

___ Scholarship and Financial Aid Information - Details about scholarships and other financial aid

___ Counselling Information - Student Resource Centre file

___ Judicial Information - Non-Academic Judicial student file

___ Residence Life Information – Residence Life Information

___ Student Services – General student file with Student Affairs

___ Medical Health Information - Student Health file

Date of Birth: (___/____/____) Health Card #: _____________________

dd/mm/yy

I hereby grant permission to Acadia University to release the specified information to the person named below.

(Please print)

Name:

Address:

Student Name (Please print)

Student ID number

Student Signature

Date

Release Of Information Permission Form