UNMC

Waiver of Disclosure of Student Record Information

I,
, attend the University of Nebraska Campus: UNMC-
and I give permission for the Tutoring Program administration at UNMC to obtain information regarding my academic progress (including, but not restricted to current grades) for the tutoring program as well as the Registrar's Office at my campus location.

I understand this information will be used only to facilitate my academic success and will be shared with university personnel working in relation to the tutoring program. This waiver is valid as long as I am an active participant of the program at my undergraduate campus, as well as while I am enrolled in an academic program at UNMC, or until written revocation is received from me.

Signature (Type your name):

Date: 09/23/2017

Type the text from the image into the space below.

Form last updated 08/24/17

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