Fillable Student Authorization for Disclosure of Information In Education (The Chickasaw Nation)

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Student Authorization for Disclosure of Information In Education (The Chickasaw Nation)

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Page 3 of 3 Form no. 04629 CS-EDU Rev. 6/2020
Student Authorization for Disclosure of Information
In Education Records
Pursuant to Family Educational Rights and Privacy Act of 1974, as amended
Instructions:
To authorize the Chickasaw Nation Higher Education Program to obtain your educational information and to authorize the Chickasaw
Nation Higher Education Program to release your educational information to individuals or the college/university you are attending
1. Fill out all appropriate fields on this form; and
2. Hand-deliver or mail the form to the address to the right.
3. Note: Forms will not be accepted without a signature.
First name:
Middle name:
Last name:
Suffix:
Birth date:
Please enter the name of the organization(s) or individual(s) to whom the authorization is given or revoked. You may enter more than one
name. Enter only ONE name per space.
Organization(s) authorized
given revoked
given revoked
given revoked
given revoked
Birth date
given revoked
given revoked
given revoked
given revoked
Authorization:
I hereby authorize the to disclose my educational record(s) to the above-mentioned organization(s) or individual(s)
and also authorize to disclose or obtain my educational record(s) to/from
Student’s signature Date
Parent/legal guardian signature (if applicable) Date
To enhance security measures, students now have the option to generate a PIN for their student files. Anyone seeking information regarding your student file will be required to verify the PIN before
information will be released. This can be done by going to www.chickasaw.net/highered and clicking on “fill form out online.” By initialing the line below you are refusing this service and allowing
organizations/individuals to retrieve information regarding your file based solely on this form.
_____
Student’s Initials
The vision of the education services division is to provide services that encourage and support academic and professional development of Chickasaw students.
Education Services
Higher Education Program
RETURN COMPLETED FORM TO:
The Chickasaw Nation
Higher Education Program
300 Rosedale Road
Ada, Oklahoma 74820
Bill Anoatubby
Governor
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Student Authorization for Disclosure of Information In Education (The Chickasaw Nation)

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Completed 31 January 2021

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