Montcalm Community College
RELEASE OF INFORMATION

Please print

I, _____________________________________________, ID # _____________,
give permission to the person named below to access the following information from my student file as noted below during the period (not to exceed one year) of _____/_____/_____ to _____/_____/_____.

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Name of individual, agency or agency representative*:

________________________________________________ required

SS#: (last four digits only) _____________ required

Password** _____________________ required

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Please check all that apply
qGrades
qTranscript
qFinancial Aid records
q Student Account Information
qOther___________________________________________

                                                        

___________________________________              _____________________
Student Signature                                                                   Date

This release of information can be revoked at any time with written authorization from the student.

*A picture ID or the last four digits of that person’s social security number and password listed above must be provided in order to release the requested information.

**Password should be something unique and not easily guessed by other individuals.  Do not share this password with anyone other than the person named above.