Permission to Release Education Record Information
Office of the Registrar
Hutchinson Community College
Hutchinson, KS 67501
620-662-3520
I hereby authorize Hutchinson Community College, Hutchinson, KS to release any and all educational records including but not limited to grades and attendance to my parent(s) or any other named individuals or entities. If parents live at the same address please list them both on line #1.
1. ________________________ 2. ________________________
Name(s) Name(s)
___________________________________________ ______________________________________
Address Address
___________________________________________ _____________________________________
City, State, Zip City, State, Zip
If person(s) above are not your parent(s), how are they related to you?
____________________________________________________________________
The released information will be used for the following purpose:
____________________________________________________________________
____________________________________________________________________
I understand that by signing this authorization, I am waiving my rights of nondisclosure of these records under federal law only as to the persons specifically identified in this document. This release does not permit the disclosure of these records to any other persons or entities without my written consent.
__________________________ ______________________________
Date Student Name (print)
______________________________
Student Signature
______________________________
Student Social Security Number