Ubatc Letter Of Recommendation Request And Authorization To Release Information Form printable pdf download

LETTER OF RECOMMENDATION REQUEST AND

AUTHORIZATION TO RELEASE INFORMATION FROM

EDUCATION RECORDS TO A THIRD PARTY

~ Please Print ~

Student ID Number: ___________________________________ Phone Number:(______)____________

Area Code

Student Legal Name: __________________________________________________________________

Last

First

Middle

I have asked ___________________________________________________ to prepare a letter

(name of faculty/staff)

of recommendation on my behalf and he/she has agreed to provide a recommendation (as

demonstrated by his/her signature below). I am completing this release form to enable the

faculty or staff member to provide the recommendation.

______________________________________

: ____________

Faculty/Staff Signature

Date

I authorization the release of information contained in my educational records regarding:

•

Academic standing or achievement

•

Performance in internships or clinical programs

•

Involvement in extracurricular activities

•

Student conduct records

•

The faculty member’s honest judgment about my character, work ethic, abilities, skill

level, goals and academic achievement

To: ________________________________________________________

(Specify complete name of person(s) or organization(s) to receive information)

Address:

_______________________________________________________

I understand that:

(1) I have the right not to consent to the release of information in my education records;

(2) I have the right to receive a copy of such records on request; and

(3) This consent will remain in effect until I revoke it in a writing delivered to UBATC

I acknowledge that my revocation will not affect disclosures that UBATC made before receiving my written

revocation. I understand further that I may waive my right to inspect and review letters of

recommendation.

I waive my right of access to this letter of recommendation.

I do not waive my right of access to this letter of recommendation.

Having acknowledged my privacy rights, I hereby authorize UBATC and the faculty/staff person named

above to release the information about me that I have indicated, some of which may be contained in my

education records:

Student Signature:___________________________________________ Date: ________________

Ubatc Letter Of Recommendation Request And Authorization To Release Information Form

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