Student Release of Information Authorization

Congratulations! You're almost done.

We can help you better if we are able to work with other agencies that know you and your family. By signing this form you are giving permission for these organizations to share information about your situation.

PURPOSE: The information received will be used to evaluate my situation and to plan for and coordinate services for me.

If you have questions, please contact Brenda Butterfield at or 541-440-4668

Student Info

Third-party Designee & Release Info

This permission expires two years from the date this document is signed. TO THOSE RECEIVING INFORMATION: State and Federal law protects this information disclosed to you. You are not authorized to release it to any agency or person not listed on this form, without specific consent of the person to whom it pertains, unless authorized by other laws.

I authorize the following individuals or agencies to receive information from Umpqua Community College:

Types of Information Shared


In accordance with The Family Educational Rights and Privacy Act (FERPA) of 1974, Umpqua Community College will only disclose confidential information from the education records of students to other third parties provided the College has written consent from the student on file. Please sign below if you give consent for the College to release your education records to the third parties listed above.

By digitally signing below, I consent that Umpqua Community College may disclose and discuss confidential information from my education record with the agencies listed above:

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Phone: 541-440-4600 | Toll Free: 800-820-5161 | Oregon Relay TTY: 711

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UCC is an equal opportunity employer and educator. 
Umpqua Community College is accredited by the Northwest Commission on Colleges and Universities.