Stark State College Gateway Student Services 6200 Frank Ave NW, North Canton, OH 44720 (330) 494-6170 | Fax-(330) 966-6598 www.starkstate.edu | studentservices@starkstate.edu

Please print in blue or black ink only.

Student Name ___ Student ID# ___

Student ID#

Date of Birth ___

I, the undersigned, hereby authorize Stark State College to release the following educational records or information to the company and/or contact person listed below:

All academic educational records.

□ The following specific records (such as grades, GPA, Class Rank): ___

Company Name ___

Contact Name ___

Address

The release of the educational records or information as stated above are for the following purpose(s):

College Admissions Application

□ Employment

2023

□ Other ___

I understand that 1) I have the right not to consent to the release of my education records; 2) I have the right to obtain a copy of such records upon request; and, 3) this consent shall remain in effect until revoked by me, in writing, and delivered to the Stark State College Academic Records/Registrar's Office, but that such revocation shall not affect disclosures previously made by Stark State College.

Student Signature _____

Date _____

Parent Signature (if student is under 18 years of age) _____ Date _____

THIS INFORMATION IS RELEASED SUBJECT TO THE CONFIDENTIALITY PROVISIONS OF 20 U.S.C. 1232g(b)(4)(B) WHICH PROHIBITS ANY FURTHER DISCLOSURE WITHOUT THE SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS, OR AS OTHERWISE PERMITTED BY FEDERAL LAW.

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FOR OFFICE USE ONLY

Process Date ___ Initials ___ G:\2020-21 Forms\REG Forms Rev 10/27/19