Release of Information Consent Form Continuing Education

Consent for Release of Education Record
This form is provided in compliance with the Family Educational Rights & Privacy Act of 1974. It is good for a one-time request and needs to be completed within 5 business days of the date shown below.

Please include your demographic information to ensure we locate the correct individual in our record system.
Name

First NameMiddle NameLast Name
Maiden Name
Address

Address

Street Address Line 2

City State ZipState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
Date
My signature at the bottom of this form indicates my consent to release portions of my Kirkwood Community College Education Record as follows:
Check all that apply:
Employer/Agency to whom the records/badges are to be released:
Name
Address
Street, City, State, Zip Code
What is the purpose for releasing this information?
Employee/student name
Employee/Student Signature *
Date*
If the person for which information is being released is under 18 years of age, the following is required.
Parent/Guardian name
Parent/Guardian Signature
Date
Should be Empty:

Consent for Release of Education Record