GEORGE MASON UNIVERSITY



George Mason University

4400 UNIVERSITY DRIVE, FAIRFAX, VA 22030

C O N S E N T T O R E L E A S E P E R S O N A L I N F O R M A T I O N

Mr. /Ms. ____________________________ G# _____________________________

I, ______________________________, hereby grant George Mason University (“Mason”), and its agents and employees, the absolute right and permission to disclose to the following persons the following information about or regarding me (which may include educational, medical, disability-related or disciplinary records), for the following purpose:

Persons and organizations to whom information will be disclosed:

Name ________________________________

Relationship ____________________________

Name ________________________________

Relationship ____________________________

Information to be disclosed:

The purpose of disclosing the information:

I attest my signature, and understand this authorization includes but is not limited to documents and written and verbal statements. This release will expire one year from the date of my signature.

___________________________

Signature

___________________

Date

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