Authorization for Release of Non-Directory Information

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

Consent to Release of Non-Directory Information

Understanding your rights: In compliance with FERPA, the Federal Family Education Rights and Privacy Act of1974 as amended, West Valley College (WVC) is prohibited from providing your confidential information to any third party including parents, spouse, guardian, etc. without a signed release. This information includes, but is not limited to, all student billing items, awarded financial aid, enrollment status and other various student information. FERPA allows schools to release Directory Information without prior consent unless a student specifically requests directory information not to be shared. See more information on FERPA.

Section A. Student Information

Name*

First Name

Initial (optional)

Last Name

Phone Number*

Permanent Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Day/Cell Phone Number*

Student ID Number*

Enter the numbers after G0

Section B. Authorization of the Release of Information by DESP

I authorize the release of information by a DESP representative

To the following party*

College or University Representative Person

Please specify name of individual or department.

Name of Person*

First Name

Last Name

Date of Birth

Address (Only if different from above)

Address Line 1

Address Line 2

City

State

ZIP Code

Name of Institution and Department*

Example: West Valley College English Department

Name of Person or Position*

Phone Number

I would like to add another party*

Yes No

Section B2. Authorization of the Release of Information

I authorize the release of information between West Valley College representative*

And the following party*

College or University Representative Individual

Please specify name of individual or department.

Name of Person*

First Name

Last Name

Date of Birth*

Address (Only if different from above)

Address Line 1

Address Line 2

City

State

ZIP Code

Name of Institution and Department*

Example: West Valley College English Department

Name of Person or Position*

Phone Number

I would like to add another party*

Yes No

Section B3. Authorization of the Release of Information

I authorize the release of information between West Valley College representative*

And the following party*

College or University Representative Individual

Please specify name of individual or department.

Name of Person*

First Name

Last Name

Date of Birth*

Address (Only if different from above)

Address Line 1

Address Line 2

City

State

ZIP Code

Name of Institution and Department

Example: West Valley College English Department

Name of Person or Position

Phone Number

Section C. Information to be Released

Financial Information

Student Account Information (tuition and fees, payments, credits and holds) Financial Aid

Note: certain information may only be obtained by a student

Academic Record and Other Student Information

Enrollment Verification Academic Transcript Class Schedule (Instructor / Location / Units) All Educational Records* Information to Support Accommodations and Student Success Disability-Related Information

Other:

*Note: this authorization does not permit the release of education records that contain medical information unless/until the student signs a specific authorization for the release of medical information in compliance with the California Confidentiality of Medical Information Act (“CMIA”).

Section D. Certification

I understand that I am authorizing West Valley College to release the selected confidential information to the party(s)listed above. This authorization does not permit the third party to make any changes.

Student’s original signature is required. Copies and faxes will not be accepted. Form must be submitted in person or have attached a copy of student’s valid government-issued photo identification (ID), such as, but not limited to, a driver’s license, other state-issued ID, or passport.

Government-issued photo ID

No File Chosen

File uploads may not work on some mobile devices.

I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance thereon. I also understand that I have the right to receive a copy of this authorization. *

Until I leave West Valley College One year from date signed Other

Desired Expiration Date*

Signature

[clear]

Use your mouse or finger to draw your signature above