RED DEER POLYTECHNIC

100 College Blvd.,

Box 5005
Red Deer, Alberta CONSENT TO RELEASE
STUDENT PERSONAL
T4N 5H5
Telephone: 403.342.3400
Fax: 403.357.3660
E-mail: registrars@rdpolytech.ca
Website: rdpolytech.ca INFORMATION
The personal information that you provide on this form is being collected under the authority of the Post-Secondary Learning Act and the Freedom of Information
and Protection of Privacy Act of Alberta. The information will be used to determine what personal information, if any, may be released or obtained from third parties.
The personal information will be protected in compliance with the provisions of the Freedom of Information and Protection of Privacy Act of Alberta. The information
will be retained by the Registrar in accordance with approved Information Management guidelines, after which it will be destroyed in a secure manner. If you have
any questions about the collection and use of this personal information, please contact the Registrar, Red Deer Polytechnic, Box 5005, Red Deer Alberta, T4N 5H5,
Telephone:403.342.3400.

PERSONAL INFORMATION
LAST NAME FIRST MIDDLE
                 
RDP STUDENT ID #
     
PHONE NUMBER ALTERNATE PHONE NUMBER E-MAIL ADDRESS
                 

I authorize Red Deer Polytechnic to release as identified below, to the following parties:
1.
NAME OF THIRD PARTY RELATIONSHIP
           
ADDRESS CITY PROVINCE
                 
POSTAL CODE PHONE NUMBER FAX NUMBER EMAIL ADDRESS
                       
2.
NAME OF THIRD PARTY RELATIONSHIP
           
ADDRESS CITY PROVINCE
                 
POSTAL CODE PHONE NUMBER FAX NUMBER EMAIL ADDRESS
                       

Please complete the following information and check where appropriate:

I authorize Red Deer Polytechnic to release the following specific information:

ACADEMIC STANDING & GRADES COUNSELLING RECORD HEALTH RECORD

DISABILITY RESOURCES
ADMISSION & REGISTRATION SECURITY RECORD (if applicable)
RECORDS
CAREER AND EMPLOYMENT
FINANCIAL RECORD
SERVICES
INFORMATION TECHNOLOGY (eg: password resets)

I authorize the above third party to act on my behalf.

OTHER (please specify):

AUTHORIZATION
Note: This authorization will be valid only during the current academic year. To withdraw consent, contact the Office of the
Registrar.
SIGNATURE DATE
           
WITNESS DATE
           
Consent to Release Student Personal Information 03/2020