Consent Form for Disclosure to Parents, Sponsors, and Recruiters

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Consent Form for Disclosure to Parents, Sponsors, and Recruiters

To: Registrar, Missouri University of Science and Technology;
Director of Enrollment Management, Shorelight

From:

Student's First Name

Middle Initial

Last Name

Student ID

Permanent Address

Date of Birth

Month

Day

Year

Types Of Information

Grades/GPAScheduleClass AttendanceBilling Statements, past due amounts, collection activityDisciplinary RecordsRecords maintained by the Office of the RegistrarStudent employment recordsRecords maintained by the Office of International Programs and Education

If you agree that the Missouri University of Science and Technology and Shorelight may disclose information from your education records to your parents/guardians, your sponsor (if applicable), and your recruiter, please sign the following consent:

I consent to the disclosure of any personally identifiable information from my education records to the individual(s)/organizations(s) named below, for reasons determined by the Missouri University of Science and Technology or Shorelight as appropriate. I understand that the purpose of the disclosure is to inform the parties listed below of my progress and status at the Missouri University of Science and Technology, as well as any circumstances affecting my attendance at Missouri University of Science and Technology. I understand that my education records may be disclosed to my Parents/Guardians through the Recruiter and that the Recruiter may only re-disclose education records to my Parents/Guardians identified below. This authorization will remain in effect for the duration of my tenure at the Missouri University of Science and Technology, but I may revoke the consent by written notice at anytime.*

Signature:

Please type your full name

Date:

Parents/Guardians:

Name(s)

Address

Telephone

Name(s)

Address

Telephone

Sponsor (if applicable):

Name(s)

Organization

Address

Telephone

Recruiter:

Name(s)

Organization

Address

Telephone

*Students cannot be denied any educational services from Missouri University of Science and Technology if they refuse to provide consent.

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