Consent to Release

CONSENT TO RELEASE

Please allow 3–5 business days for processing. It may take longer during busy times.
Student’s Name
Student ID #
VCCCD ID Number
Student's Phone Number
Please provide the best number to reach you in the event we have any questions.Format: (000) 000-0000.
Student's Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you adding or removing consent from your EAC records?

DISCLOSURE TO PARENTS/GUARDIANS/OTHERS
As allowed by federal regulations, the Family Educational Rights & Privacy Act (FERPA), Oxnard College EAC releases information contained in a student’s educational record to a student’s parents/guardians (both custodial and non-custodial) if the student gives consent. If you wish your parent/guardian/others to have access to your information, please fill in the following information:

Please list Parent(s) or Guardian(s) or Other individuals and your relationship to them:
Name of Parent/Guardian/Other:
Relationship:
i.e. "Mom", Dad", "Sister", "Friend", etc.
Please Initial:
Student's Initials
Would you like to add someone else?
Name of Parent/Guardian/Other:
Relationship:
i.e. "Mom", Dad", "Sister", "Friend", etc.
Please Initial:
Student's Initials
Would you like to add someone else?
Name of Parent/Guardian/Other:
Relationship:
i.e. "Mom", Dad", "Sister", "Friend", etc.
Please Initial:
Student's Initials
Would you like to add someone else?
Name of Parent/Guardian/Other:
Relationship:
i.e. "Mom", Dad", "Sister", "Friend", etc.
Please Initial:
Student's Initials
Would you like to add someone else?
Name of Parent/Guardian/Other:
Relationship:
i.e. "Mom", Dad", "Sister", "Friend", etc.
Please Initial:
Student's Initials

REMOVAL OF CONSENT
I would like to revoke my prior consent for the EAC to release information from my educational records.
Name of Parent/Guardian/Other:
Relationship:
i.e. "Mom", Dad", "Sister", "Friend", etc.
Please Initial:
Student's Initials
Would you like to remove someone else?
Name of Parent/Guardian/Other:
Relationship:
i.e. "Mom", Dad", "Sister", "Friend", etc.
Please Initial:
Student's Initials
Would you like to remove someone else?
Name of Parent/Guardian/Other:
Relationship:
i.e. "Mom", Dad", "Sister", "Friend", etc.
Please Initial:
Student's Initials

THIS AUTHORIZATION SHALL REMAIN IN EFFECT UNTIL REVOKED OR CHANGED IN WRITING BY THE UNDERSIGNED
Student Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearToday's Date
Should be Empty:

CONSENT TO RELEASE