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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