VALENCIA COMMUNITY COLLEGE INTERNATIONAL ADMISSIONS THIRD PARTY RELEASE FORM
Please Print All Information Student’s Name_____________________________________________ Valencia ID_______________________ Student’s Mailing Address_____________________________________ City/State/Zip_____________________ Student’s Phone Number:____________________ Student’s E-mail DECLARATION: The student whose signature appears below has authorized release to the following Third Party Individual for the specified record: Name of Individual _______________________________________
Relationship to Student_________________
Mailing Address___________________________________________City/State/Zip_________________________ Telephone________________________________________________ E-mail_______________________________ PURPOSE/TYPE of DISCLOSURE: Pick up SEVIS I-20 Assist in processing my Admission Application Packet Other______________________________________ Student’s Declaration: I acknowledge I am aware of this request to release my information to the Third Party specified above. I understand this authorization is valid one time for a single release of information. I further release Valencia Community College from any and all liability for release of the above named information.
Student’s Signature___________________________________________
Date_____________________________
Valencia Community College-International Admissions P.O. Box 3028 Orlando, Florida 32802 East Campus Fax: 407-582-8909
West Campus Fax: 407-582-1866
Osceola Campus Fax: 407-582-4181
For Office Use Only Third Party Individual Signature______________________________ Date____________________ Identification of Third Party Individual Verified (attach copy )
Revised 4/9/2010