Authorization to Release Information

Authorization to Release Information
To request the release of your student information, please complete the form below. Valid photo ID required.

Student Information:
BMCC ID or SSN:
Name

First NameLast Name
MI
Other Names Used
Address

Mailing Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Phone
Format: (000) 000-0000.
Email
example@example.com
Please complete the section below indicating who this authorization is for and the date through which this authorization is valid.
Description (e.g. parent, employer, banking, institution)
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Name of Authorized person

FIRST NAMELAST NAME
Address of Authorized person

MAILING ADDRESS

Street Address Line 2

CITYState / Province

Postal / Zip Code
EMAIL of Authorized person
example@example.com
Phone number of Authorized person
Format: (000) 000-0000.
Select the Academic Information that can be shared with this person (check all that apply)
Upload your Valid Photo ID. Example: Valid Drivers License (Required)

Cancelof
By signing below, I hereby give my written consent to the Registrar's Office at Blue Mountain Community College authorization to release information to the recipient named above.
Student Signature
Date

MonthDayYear
Date
Date Blue Mountain Community College is an equal opportunity educator and employer.
Should be Empty: