SDSM&T CERTIFICATION CONSENT FORM

SDSM&T CERTIFICATION CONSENT FORM

To view the complete form, it may be necessary to maximize/enlarge this window.

PLEASE NOTE: students may print out a self-service enrollment verification form from WebAdvisor to present to insurance companies or other parties. Click on Enrollment Verification Request on the WebAdvisor for Students menu.

For other types of verification complete the form below. Education records are protected by the Family Educational Rights and Privacy Act. In most cases, only the student can authorize release of their records. Academic and Enrollment Services will release information contained in your academic records, (i.e., full time student status, term of enrollment, good student discount status) to insurance companies, to parents, or to other concerned parties, but we must have your approval as evidenced by this signed release form. If you would like information released, please complete this form, print it and sign it before returning it to the AES office in the O’Harra Building or fax it to 605/394-1268.

Name:

Date:

Home Address:


	City	State	Zip

Telephone:

ID#:

Student Signature:

Information to be released: (check all appropriate boxes)

Full Time Status - specify semester(s):

Pre-registered - specify semester(s):

GPA - specify semester(s):

# of credit hours - specify semester(s):

Other - specify:

Will pick up - specify date:

Please Mail to:


	City	State	Zip
and/or Fax to:

Other directions:

To be completed by Office Staff:
Completed by: ________________________________________________
Mailed, Faxed, or Picked Up: ______________________________________
Comments: __________________________________________________