Name of Student: ___________________________________________________
NAID: ___________________________________________________________
DOB:____________________________________________________________

I, the undersigned, hereby authorize NDSU to release the following education records and information (identify records or type of records) _________________________________________________________________
_________________________________________________________________
_________________________________________________________________
to (Name and Address of Person/Agency to Receive Information) _________________________________________________________________
for the purpose of _________________________________________________________________
_________________________________________________________________
_________________________________________________________________

I understand further that: (1) I have the right not to consent to the release of my education records; (2) I have a right to receive of copy of such records upon request; (3) and that this consent shall remain in effect until revoked by me, in writing, and delivered to NDSU, but that any such revocation shall not affect disclosures previously made by NDSU prior to the receipt of any such written revocation.

______________________________
Student's Signature

______________________________
Date

______________________________
Signature of Parent or Guardian
if student is under 18 years of age

THIS INFORMATION IS RELEASED SUBJECT TO THE CONFIDENTIALITY PROVISIONS OF APPROPRIATE STATE AND FEDERAL LAWS AND REGULATIONS WHICH PROHIBIT ANY FURTHER DISCLOSURE OF THIS INFORMATION WITHOUT THE SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS, OR AS OTHERWISE PERMITTED BY SUCH REGULATIONS.