Release of Information Form
I, ________________________________________________, the undersigned, hereby authorize the following individual, agency, institution or organization, Canyon College (Records Custodian), to release and provide to:
Fax: ( ______ ) ________ - _______________ with copies of documents as may be listed below. I acknowledge that I understand the purpose of the request and that authorization is hereby granted voluntarily.
Student Name (Last, First, Middle): _____________________________________________________
Phone: ( ______ ) ______ - ___________ Date of Birth (mm/dd/yy): ______ / ______ / ______
Requested Information or Documents:
[ ] Student academic report
[ ] Student enrollment status
[ ] Other (Please explain in detail): ________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________
NOTE: I understand that this release is valid for a period of one hundred and twenty (120) days. I further understand that I may cancel or revoke this authorization at any time in writing.
Dated this _____________ day of ______________________________________, ________________
By my signature below, I consent to the release of the above listed information / documents.
Printed Name of Student: _______________________________________________________________
Signature of Student: __________________________________________________________________