Step 4 of 4
Student Release of Information Authorization

Congratulations! You're almost done.

This form must be completed by students working for companies that are paying course fees and other costs using a direct bill option. Completing this form grants permission to UCC to share information with the designated employer contact. Before beginning this form, ensure that you have obtained the name of your Designated Employer RMC Representative.

Read Carefully - This form must be completed correctly and accurately or else the registration process will be suspended pending correction. You should be following the how-to-register document provided by your employer. If you have not received that document, send an email to The Third-Party Designee Section must match your company information.

If you have questions, please contact the RMC program advisor, Gary Gray at 541-440-4703

Student Info

Third-party Designee & Release Info

Example: "Sam Smith or Designee" ("or Designee" must be included)
Example: "Employer (Acme Markets)"

The choices below allow you to limit the information released but may impact your employer program participation. Please consult with your employer before selecting these options.

Authentication Info

Security Question and Answer (It is required that you share both your question and answer with your designee)

When the party named above contacts Umpqua Community College, he/she will be asked to authenticate his/her identity by providing the personal security question answer. You, the student, should choose one short personal security question and provide it to your third party contact. Do not choose a question that could easily be guessed. If your third party contact is not able to correctly provide the correct answer to the personal security question, Umpqua Community College will not release any information from your record. If you forget or misplace your personal security question, you must come to the Enrollment Services Office on campus to complete a new release form.


In accordance with The Family Educational Rights and Privacy Act (FERPA) of 1974, Umpqua Community College will only disclose confidential information from the education records of students to parents or other third parties provided the College has written consent from the student on file. Please sign below and return to the Enrollment Services Office (Registration Office) if you give consent for the College to release your education records to the third-party listed above. Please Note: This release form will remain valid until revoked by the student.

By digitally signing below, I consent that Umpqua Community College may disclose and discuss confidential information from my education record with the individual listed above:

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