Release of Information

Student Information

(*required fields)

First Name

Last Name

Middle Initial

Student ID

Star ID

Email Address

Birthdate

I hereby authorize Minnesota State Community and Technical College (M State) to release and/or orally discuss the education records described below about me to:

Delete_ID_
Release Information
Name Relationship Department (list N/A if none) The specific records covered by this release are: The specific records covered by this release are: Accounts Receivable (itemized charges or credits) Financial Aid Registration (add/drop/withdrawal) Grade Reports (end of semester) Faculty (Attendance/Academic Progress/Performance/Behavior) Accessibility Resources All of the above I rescind my previous authorization to release information to the individual(s) noted above Other Other information to release: This authorization to release student information will be valid until rescinded or changed by the student.

Insert Contact for Release

Delete_ID_
Do Not Release Information
Do Not Release DO NOT RELEASE

Insert Do Not Release

Authorization

In place of your signature, please type your full legal name.

eSignature*

Date*