Consent To Release Records - University Of Washington printable pdf download

Consent To Release Records - University Of Washington

UNIVERSITY OF WASHINGTON

Office of the Registrar

Seattle, Washington 98195

CONSENT TO RELEASE RECORDS

I, ____________________________________________, hereby give my consent to the

(Student Name)

University of Washington to release my_______________________________________

(specify records to be released)

to ___________________________________________________ for the purpose of

(Specific party or class of parties to receive records)

______________________________________________________________________ .

(State exact purpose of release)

I do / do not request that the University of Washington provide me a copy of the records

(circle one)

released pursuant to this consent.

I understand that the University of Washington will provide the records cited above only

with the condition that the receiving party or parties may not disclose the information,

other than directory information, to other parties without my further consent, unless such

other parties are otherwise eligible under federal law to receive the records. I further

understand that any statements that I have placed in my records commenting on contested

information contained in the records listed above will be released along with the records

to which they relate.

____________________________________________________ / __________________

Signature of Student

Date

Consent To Release Records - University Of Washington