Authorization for Disclosure of Non-Directory Information
Disclosure Statement
I understand this form may only be used to disclosure information to a single individual or employer/organization/school and I will have to submit this form multiple times to disclose information to additional individuals or employers/organizations/school
Please select...
Yes
No
I agree to use an electronic signature in lieu of signing a physical form
Yes, I agree
No, I do not agree. Please provide me with a form I can physically sign.
Personal Information
First Name
Middle Name
Last Name
Kenzie Academy Email
Account Verification
To safeguard your information, you must provide at least 3 required pieces of information regarding your account.
Verification Type #1
Please select...
Student ID
Advisor's name
Academic program
First term of enrollment (your start date)
Name of high school from which you graduated
Verification Answer #1
Verification Type #2
Please select...
Student ID
Advisor's name
Academic program
First term of enrollment (your start date)
Name of high school from which you graduated
Verification Answer #2
Verification Type #3
Please select...
Student ID
Advisor's name
Academic program
First term of enrollment (your start date)
Name of high school from which you graduated
Verification Answer #3
Release Information
Who will you be releasing this information too?
Please select...
Choice A
Choice B
Choice C
First Name
Last Name
Name of Employer/School/Organization
Address
City
State
Zip Code
Release information
What information would you like released? Check all that apply
Academic Records
Financial Records
Grades
Employer Reimbursement (includes academic and financial records)
GPA
Immigration Information
Other
If other, please explain
Electronic Signature
If you agreed to use electronic signatures earlier, please enter your full name here.
Enter your full name
Today's Date
