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Student
| Name: | _________________________________ | Student ID: | _________________________________ |
| SSN: | _________________________________ | DOB: | _________________________________ |
| Guardian: | _________________________________ | Relation: | _________________________________ |
| Phone: | _________________________________ | Email: | _________________________________ |
| Address: | _________________________________ |
Transfer From
| School: | _________________________________ | Name: | _________________________________ |
| Fax: | _________________________________ | Email: | _________________________________ |
| Phone 1: | _________________________________ | Phone 2: | _________________________________ |
| Address: | _________________________________ |
Transfer To
| Name: | _________________________________ | Organization: | _________________________________ |
| Fax: | _________________________________ | Email: | _________________________________ |
| Phone 1: | _________________________________ | Phone 2: | _________________________________ |
| Address: | _________________________________ |
Authorized Information to Disclose
Reasons for Disclosure
I, the student or legal guardian, understand that I may revoke my consent, in writing, at any time. I understand that my information will be held in the strictest confidence and will be read, shared, and held by no parties other than those who transfer the information and those who receive it.
(Student's Signature)
(Legal Guardian's Signature)
(Date)
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Index of Printable Contract Examples
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