Consent for Release of Student Information
National Center on Deafness Jeanne Chisholm Hall 18111 Nordhoff Street Northridge, CA 91330-8267 818-677-2614 818-677-7192
Permission is hereby given to:
Permission is hereby given to:
Name of Faculty/Administrator/Staff
*
of the National Center on Deafness
to provide the following information to:
to provide the following information to:
(Name of parent, guardian or other person to whom information about the student can be released)
*
Relationship to Student
*
Indicate specific information that may be released
*
I hereby authorize the person named above to release the information described above. I also understand that I have the right to cancel my permission to release information at any time before it is released and that this signed consent will expire on the date indicated below.
I hereby authorize the person named above to release the information described above. I also understand that I have the right to cancel my permission to release information at any time before it is released and that this signed consent will expire on the date indicated below.
Student's Signature
*
Signature of parent/guardian (if minor)
*
Student print name and CSUN ID #
*
Expiration Date
*
*
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