ࡱ> <>;'` bjbjVwVw 444 < < < < H !$h h h h h h h h #######$%h(#h h #h h #"h h ##h \ /< $:l#4#0!$(^4((h :  6 h h h ## h h h !$< <  AUTHORIZATION TO RELEASE INFORMATION Eastern Illinois University Charleston, Illinois Student information is confidential under the Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. 1232g. Therefore, your authorization is necessary to permit the release of information concerning your academic progress to your parent(s), guardian, or designee. This AUTHORIZATION TO RELEASE INFORMATION is for the above stated purpose. I, ____________________________, hereby authorize the appropriate employee of Eastern Illinois University to release academic information to my parent(s), guardian or designee. I understand that this authorization is being used to allow Eastern Illinois University and my parent(s), guardian or designee to communicate and work together. I understand that I have a right to be told what information was exchanged. I understand that this information will not be disclosed to others not listed below, except for those individuals or entities specified in FERPA. I understand that I may revoke this authorization in writing at any time. I understand that this authorization shall be valid during my academic career unless specified otherwise. (Expiration date, if applicable:___________________) Please list below names and addresses ____________________________ of appropriate persons: Student Name (please print) ________________________________ ____________________________ ________________________________ Signature of Student ________________________________ ________________________________ ____________________________ ________________________________ E# ________________________________ ________________________________ ____________________________ ________________________________ Date ________________________________ Note to student: If this release is being sent by mail, a copy of your photo i.d. should accompany it. If presenting this document in person, bring your photo i.d. with you. Eastern Illinois University Staff or Faculty member, if you verified the 鶹ý identity through a Photo I.D., Panther Card, or Drivers License, please sign below and include your campus phone number. Verified by Photo I.D. _________________________________________________ _______________ Eastern Illinois University staff or faculty signature EIU Phone # %&Xx )*.9AC[^˼xxxk[k[O@[Oh:-}h}OJPJQJ^Jh}OJPJQJ^Jh}h}5OJPJQJ^Jh}5OJPJQJ^Jh}56OJPJQJ^J"h}hy@56OJPJQJ^JhA%h:-}hy@OJPJQJ^Jh:-}hy@>*OJPJQJ^Jh:-}hy@OJPJQJ^Jh:-}hy@5OJPJQJ^Jh:-}hy@5OJPJQJ^J'h:-}hy@5CJOJPJQJ^JaJ%&BWX g h e f   T U 2 3  E a gdy@$a$gdy@ +k)*)gd}gdy@21h:p}/ =!"#$% @`@ y@NormalCJ_HaJmH sH tH DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k@(No List %&BWX ghefTU23Ea+k)*) 00000000000000000000000000000000000000000@0@0@0    wpxydzij{d|4}o~D͎  :["\["["ՒՒ..7BBN P P X a      6AALVV W ` k k    =*urn:schemas-microsoft-com:office:smarttags PlaceType=*urn:schemas-microsoft-com:office:smarttags PlaceName9*urn:schemas-microsoft-com:office:smarttagsState8*urn:schemas-microsoft-com:office:smarttagsCity9*urn:schemas-microsoft-com:office:smarttagsplace x{  -/ 3333.9AC  .-KT7Mw9zPnj2:Y*8X]f1)Bd{8}*cEOh_mw|k+z !<it'446~>_ce7 N$4M  $ N? L P ! J W g O ! UR k # H aS q    - hH a e Y[ek,.(]E )MR\ 2ETb fr*D]>_pylxe%0XIIMXeh4klWUg,aLM`m&ns+u u *!t!'!7!d!'n!|!/$"2"4H"NZ"0#[6#Q8#yH#T#$g#:g#$$$g$x$?x$%f+%r]%*&/&d&Bh&$'$+'I'K'_'X{'l{'?(5(^(u( |(P}() )+)2){) * ***A *&*w'*93*d:*H*tQ*Fc*u*+d$+9+<+ ,g,,4,gq,v,- -*-A-y-z-u.}E.//"/*/.+/{./M/h^/00A0f0 1,B1P1Q122H2<_2u23$3A3W3e3l3>|3p34m4&4s(4;4N4R45 5H#5V5Gc5"p56C6Q6~6*"7.7w67X7a7~18f80I9w9<:k:!;C;M;S;fU;h; < < <@<:D<d<m<==BG= r= >8>L>x>b?O+?/?2?7?@+@N@"A/AsA B5B9BXBXB C$%C WCqCQD4DEDeD3E#0EfEwElFJEFFFgFGi GG!Gt@GNG{WGWGeG%|GH%HWHlZH[HGpHwrH)I0ISGIcI@vI J6JuJ\K5KJTYyzI+i0"*].J i Dk >OeMxN(y \<12E$IlyZ sf7@_E8Y&mr~ w .BZjgk{I~#I=iw4x Bcy5 2 6 T&)k?lSx0FJBLeq#x.DEy +2y!@]y1:KYJr G1J23OW CZJDK`AQfas4 vNqNjT` !E&FH9!<+ KKXRW``kIQfw}: "/8h7U8jx\(?*bd k: *"-5HvpIu]90n4 +EY:["o(429R"l}T8$AoINVqC;a>&? G|bp'',71V)4,9;E"MzM@`tiz,:5aAFS/y\ x2DC;L p!wSa'Pfp>HHXg8Rld'1>DOvq+4JkH =wW?H7n0v2.CH|M_~M^;hdQ+ lz~%F V]dgnrru} 5" IWYGc+i!#w+./K+W~s ?=Q]~{4>ó<[ b 5a F P*Yt@ N-;f@IA]hx'@L!PW(336HOlt$;[ac- b)ALqfS *6:\sjz =Bn }<$jLrt~)* @L L L L  @UnknownGz Times New Roman5Symbol3& z ArialA& Arial NarrowI& ??Arial Unicode MSK"Adobe Heiti Std R"qh^GzGq8q8!x24d 2QHX)?y@$AUTHORIZATION TO RELEASE INFORMATION ssgrounds ssgroundsOh+'0 (4 T ` lx(AUTHORIZATION TO RELEASE INFORMATION ssgrounds Normal.dot ssgrounds1Microsoft Office Word@b@$c/@̾w/q8՜.+,0$ hp  Eastern Illinois University ' %AUTHORIZATION TO RELEASE INFORMATION Title  !"#$%&'()*,-./012456789:=Root Entry Fp$/?Data 1Table(WordDocument4SummaryInformation(+DocumentSummaryInformation83CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q