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Authorization to Release Information

Student ID#
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Telephone #*
Academic Program
I give permission to River Valley Community College to release information on my (check all that apply)*
- Select All
- Application to the College
- Enrollment
- Attendance
- Grades
- Billing
- Financial Aid
- Other
You selected "Other." Please specify.
My information may be released to:
Name*
Address*

This address will be used to confirm the identity of the person to which you are giving permission.
Signature*
Date*
MM slash DD slash YYYY

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