Record Release Authorization Request | Pipe Trades Training Center

RECORD RELEASE AUTHORIZATION

REQUEST

Before completing this form, please review the following.

If you are requesting any of the following, DO NOT complete this form and instead use the appropriate links below to submit your request by email.

Journeylevel Completion Certificate Verification for Skilled & Trained Workforce Requirements
U.S. Department of Labor (DOL) Certificate for Federally Funded Projects

In compliance with the federal Family Education Rights and Privacy Act of 1974 (FERPA), the Pipe Trades Training Center is prohibited from providing certain information from your training records to a third party. This restriction applies, but is not limited, to your parents/guardian, spouse, or sponsor.

You may at your discretion, grant the Pipe Trades Training Center permission to release information about your training record information to a third party by submitting the Record Release Authorization Request form below. You must complete a separate form for each third party to whom you grant or withhold access. The specified information will be made available only if requested by the authorized third party. Upon requesting information, the authorized third party will need to include a copy of your request submission. The Pipe Trades Training Center will not automatically send information to a third party.

For more Information regarding the Family Education Rights and Privacy Act see below.

Protecting Student Privacy - U.S. Department of Education

A Parent's Guide of the Family Educational Rights and Privacy Act - U.S. Department of Education

An Eligible Student Guide to the Family Educational Rights and Privacy Act - U.S. Department of Education

Trainee Information

First Name

Last Name

UA Number

Phone

Release Options (Please select one of the following options)

ALLOW release of my student record information to the individual indicated on this form

WITHHOLD release of my directory information & student record information to the following individual

WITHHOLD release of my directory information & student record information to anyone but me

Third-Party Designee Information

Designee First Name

Designee Last Name

Relation to Trainee or Agency

Designee Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Designee Email

Designee Phone

Information Types Allowed

Select all information you are authorizing to release or withhold

Grades, GPA, registration, registration hold, Academic Progress status, attendance

Billing statements, charges, credits, payments, past due amounts, collections activity

Application data, enrollment information, demographics

Disciplinary, Title IX, Student Code of Conduct information, records related to incidents addressed in the Pipe Trades Training Center policy

Trainee Certification

Signature

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By signing my name I give consent to Pipe Trades Training Center to release/withhold my training information to the third party designee listed above. This form will be kept on permanent file until I revoke it at any time by submitting a written request. This authorization does not permit the listed party to make any changes to my training records.

Proof of Identification

Attach a picture of any form of photo identification (driver's license, passport, student ID, etc.)

Trainee Information

Third-Party Designee Information

Information Types Allowed

Trainee Certification

PTTC is accredited by the Commission of the Council on Occupational Education.