Summer at IUPUI

IUPUI Rescind Prior Consent Form

Name _____________________________________________________
Ten Digit Student Identification Number  ___________________________
Date ______________________________________________________

Rescind Consent:
I hereby rescind the prior consent granted to __________________________________________ (School, department or individual’s name) to release and/or discuss private student academic record information with the individual listed below.
Authorization Previously Granted To:
Name of Individual _____________________________________________________
Relationship to Student __________________________________________________

 
Student Signature _____________________________ Date_________________