You are hereby authorized to disclose, make available, and release academic grades, academic records, housing and campus activity information and actions, and information regarding disciplinary proceedings and outcomes relating to or concerning me to my parents, legal guardian, or others whom I specify below without my further consent, until further notice.

This authorization shall be considered as a waiver of any and all my rights and/or privileges as provided under the Family Rights and Privacy Act of 1974, as amended. A photocopy of this authorization shall be considered as valid as the originally signed document.

Student's Printed Name: _____________________________________________________________

Student's Signature: ________________________________________________________________

RU ID: __________   

Date: __________

I authorize Radford University to release information to:

I understand that by authorizing the release of my educational records that does not relieve me of responsibility for my conduct and obligation to the University.  I understand that this permission remains in effect until I revoke or amend it in writing and I further understand that while this release allows for communication to occur between Radford University and said authorized individuals that the release of hard-copy documents will only occur upon the receipt of a signed request by me or the authorized individual(s).

Copy to:
Dean of Student's Office
Advising Center of the Student's Major: _____________

Rev. 01/19/00
Rev. 05/24/04