Authorization to Release Student Information Request Form

What? You (student) will use this form to give the university permission to release your personal information (e.g. your marks or registration information) to a third party, such as a parent.

Who? You (student) must complete, date and sign this form. Part 2 must be done in-person at the Office of the Registrar. Faxed or scanned copies will not be accepted.

When? These forms do not have a deadline. The length of time for requests depends on when you complete step #2 from the instructions listed below under the How? heading.

How? The submission of this form requires a 2-step process:
Step 1 - Complete this form entirely and submit it.
Step 2 - Come in to the Office of the Registrar, and present your valid photo ID (government or university ID).

Note: The 3rd party being granted access may not accompany the student during this step. ONLY the student is permitted to be present when the authorization is finalized.

Student Information
Student Name Student Name First Last
Student Number
Must be 9 digits. Currently Entered: 2 digits.
Student Email
Phone Phone - ### - ### ####
Program
Authorized Individual

I authorize Ontario Tech University to release protected student information about my general student record including admissions, grades, current enrolment, status, program, student account information, and any other academic record deemed necessary.

This information may be released to:
Name Name First Last
Name of Authorized Individual
Date of Birth Date of Birth / MM / DD YYYY

D.O.B. of Authorized Individual
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Address of Authorized Individual
I do not authorize the release of the following information

List anything you do not want disclosed to the authorized individual.

Type NA if not applicable
This information is being released for the following reasons:

Note: If you do not desire to state a specific purpose, type "at the request of the individual"
This authorization shall remain in effect until: This authorization shall remain in effect until: / MM / DD YYYY

Expiry date is mandatory. Student can always submit a new request after the stated date.
Consent
I understand that the individual being granted access may not accompany me during step 2. Only I am permitted to be present when the authorization is finalized.

I understand that the individual being granted access may not accompany me during step 2. Only I am permitted to be present when the authorization is finalized. I understand

Refer to the "Note" section within the instruction details of the 2-step process.
Student rights: You have the right to inspect the contents of your client file and the information released, and if you disagree with the file contents, to submit an amendment to your records.

Student rights: You have the right to inspect the contents of your client file and the information released, and if you disagree with the file contents, to submit an amendment to your records. I understand
Revocation of consent: You have the right to revoke this authorization in writing at any time by sending such written notification to the Office of the Registrar’s address with both your signature and that of a witness. However, your revocation will not impact information already released, or release of some information to insurance companies with the legal right to contest a claim.

Revocation of consent: You have the right to revoke this authorization in writing at any time by sending such written notification to the Office of the Registrar’s address with both your signature and that of a witness. However, your revocation will not impact information already released, or release of some information to insurance companies with the legal right to contest a claim. I understand
This authorization is governed by the Freedom of Information and Protection of Privacy Act (R.S.O. 1990, Chapter F31), as well as other applicable provincial and federal laws. Such laws prohibit re-disclosure of any information disclosed to the recipient pursuant to this authorization unless this authorization specifically authorizes redisclosure.

This authorization is governed by the Freedom of Information and Protection of Privacy Act (R.S.O. 1990, Chapter F31), as well as other applicable provincial and federal laws. Such laws prohibit re-disclosure of any information disclosed to the recipient pursuant to this authorization unless this authorization specifically authorizes redisclosure. I understand
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
Personal information on this form is collected under the authority of the University of Ontario Institute of Technology Act, SO 2002, c. 8, Sch. O. and will be collected, protected, used, disclosed and retained in compliance with Ontario’s Freedom of Information and Protection of Privacy Act R.S.O. 1990, c. F.31. This information will be used for education, administrative and statistical purposes within the university. Questions regarding the collection of your personal information may be directed to the Office of the Registrar, 2000 Simcoe Street North, Oshawa, ON L1G 0C5, 905.721.3190, email: connect@ontariotechu.ca.

If you require this information in an alternative format due to disability, please email records@ontariotechu.ca.
FOR OFFICE USE ONLY:
Processed By and Date:

Authorization to Release Student Information Request Form

Authorization to Release Student Information Request Form

Student Information

Authorized Individual

Consent