Student Request to Release Information

Student’s Name: _____ ______ Student ID#:_________________________

I understand that the Family Educational Rights and Privacy Act of 1974 as amended (FERPA) protects the privacy
of my student education records and limits access to the information contained in those records.

I have indicated below the individual(s) who may have information from my education records:

1) Name: Relationship:
Address:
City, State, Zip:
Phone: ( )

2) Name: Relationship:
Address:
City, State, Zip:
Phone: ( )

PLEASE INITIAL ALL AREAS THAT APPLY:

1. If they ask, I want the above named individual(s) to be informed about:

My grades and academic standing
My attendance records
My financial standing with the school
2. Please inform the above named individual(s) if the school becomes aware of my being
hospitalized or treated for any emergency of life-threatening medical or psychological condition.
3. Please inform the above named individual(s) of any circumstances (e.g., missing classes,
disruptive or erratic behavior, etc.) if the school believes it is in my best interest to do so.
4. _______Please allow Career Services to supply and obtain information about my education and
employment.
5. Additional information that may be obtained by the above named individual(s) (must be listed):
_____________
_______ __________________________________
________________________________________________________________________________________

__________________________________________ ___________________
Student’s Signature Date
___
Print Name
06/27/2007

Copyright © 2007 Corinthian Colleges, Inc. (CCi) Santa Ana, California, 92707. All rights reserved.
The information contained herein is proprietary and confidential. Any disclosure to unauthorized persons would be harmful to the
Company's business and is expressly prohibited.