Consent for Release of Student Information

Permission is hereby given to:

Name of Faculty/Administrator/Staff*

of the National Center on Deafness

(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*

Student's Signature*

Signature of parent/guardian (if minor)*

Student print name and CSUN ID #*

Expiration Date*

Send me a copy of my responses