Release of Information Form

Lower Columbia College, in compliance with the Family Educational Rights and Privacy Act of 1974 (FERPA), requires the written consent of the student authorizing the disclosure of non-directory personal information to a third party. The authorization must include: the specific information to be released; the party or class of parties to whom the information is to be released; the purpose of the release; the date; and the student's signature.

This document does not authorize the person(s) designated to initiate or complete transactions, make changes to the student record, or serve as a representative on the student's behalf.

Please complete the following form and upload a photo of your valid photo ID.

Your submission will be encrypted and protected from disclosure. If you don't want to send digital copy of your ID, visit the One-Stop Center in person to verify your ID (on campus in the Admissions Center Building).

Name*

First NameLast Name

ctcLink Student ID Number*

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Type of Release (choose only one):*

Release of information until revoked by me in writing and delivered to LCCRelease of Information for a specified time frame (list below)I wish to revoke the current release of information I have on record for the following person or institution

Start Date*

Date

End Date*

Date

I wish to revoke the current release of information I have on record for the following person or institution:*

Student Records to be Released (check all that apply):*

Enrollment Records – registration and enrollment information.Billing and Financial Aid – charges, payments, financial aid, VA, or other funding informationGrades – term grades and GPA in the form of an unofficial transcript (note: does not include official transcripts)Student Course ScheduleAll of the AboveOther

Please select a password that will be used to verify whether a third party is allowed to access your information. Share this password with each person you are listing on this form. This can be a name, word, number, or short phrase.*

E.g., "Banana"

Who are you releasing records to (list person(s), institution or agency):*

Please provide a reason for release of records:*

Upload a photo of your valid photo ID. This is required to confirm your identity and must be completed to submit the form.

Upload photo ID*

This is required to confirm your identity and must be completed to submit the form.

Photo ID*

I, {firstAnd}, understand that the information specified on this form is being released to a third party at my request, with the understanding that this party will not release it to any other parties. Lower Columbia College is hereby released from all legal responsibility or liability for the release of the above-referenced information. This release will be in effect until I revoke it in writing.

Please sign below to agree to the above statement*

Lower Columbia College is required to keep original signed consent forms.

Students are advised to keep a copy of this form with their records.

Date

Lower Columbia College does not discriminate on the basis of sex and prohibits sex discrimination in any education program or activity that it operates, as required by Title IX, including in admission and employment. Lower Columbia College provides equal opportunity in education and employment and does not discriminate on the basis of race, color, national origin, citizenship or immigration status, age, perceived or actual physical or mental disability, pregnancy, genetic information, sex, sexual orientation, gender identity, marital status, creed, religion, veteran or military status, or use of a trained guide dog or service animal as required by Title VI of the Civil Rights Act of 1964, Title VII of the Civil Rights Act of 1964, Title IX of the Educational Amendments of 1972, Sections 504 and 508 of the Rehabilitation Act of 1973, the Americans with Disabilities Act and ADA Amendment Act, the Age Discrimination Act of 1975, the Violence Against Women Reauthorization Act and Washington State's Law Against Discrimination, Chapter 49.60 RCW and their implementing regulations. All inquiriesregarding compliance with Title IX, access, equal opportunity and/or grievance procedures should be directed to Vice President of Foundation, HR & LegalAffairs, 1600 Maple Street, PO Box 3010, Longview, WA 98632, title9@lowercolumbia.edu, Phone number, (360) 442-2120, Phone number/TTY (800) 833-6388. The notice of nondiscrimination is located at :https://lowercolumbia.edu/disclosure/non-discrimination/

Student Consent for Release of Information