First Name:
Last Name:
Student ID:
It is the policy of Klamath Community College, in accordance with the Family Education Rights and Privacy Act (FERPA), to withhold personally identifiable information contained in our students’ education records unless the student has consented to disclosure. Private information, such as grades, class schedules, the student’s account, and financial aid awards may not be released without express consent from the student. Signing this form provides such consent, according to the information designated for release and to whom it is to be released.
I authorize Klamath Community College to release the following educational records, upon request, to the persons listed below, for the purpose of keeping them informed regarding my education at Klamath Community College.
Please select all that apply:
Persons to whom information can be released:
Name: Reynda Scobee
Relationship: STEP Coordinator
Name: Valrie Davidson
Relationship: STEP Career Coach
Name:
Relationship:
All listed persons will have access to the selected information/ departments above. If a person shall have access to different information than listed, student must complete a separate form for said person.
Please provide the contact information for the previously stated persons to whom information can be released.
Mailing Address: 7390 S. 6th St., Klamath Falls OR 97603
_________________________________________________________
Phone Number: (541) 880-2343
Email: Scobee@klamathcc.edu
________________________________________________
Phone Number: (541) 880-2295
Email: valrie.davidson@klamathcc.edu
Address:
Phone Number:
Email:
I acknowledge by my digital signature that I understand that, although I am not required to release my records, I am giving my consent to release the designated information to the above named person(s). I understand that this release will remain in effect unless I revoke such consent in writing and the revocation is received and processed by Klamath Community College.
Date:
