Consent Form

for Disclosure to Parents/Guardians, Financial Sponsors, and Agents

To: Registrar, Chicago State University
      Managing Director, Caleb Westberg

If you see this don't fill out this input box.

Student Information

*First Name:

Middle Initial

*Last Name

*Student ID

*CSU Email

Phone Number

Date of Birth

*Month

Please Select January February March April May June July August September October November December

*Day

Please Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

*Year

Please Select 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Consent

Please read the following statement regarding the disclosure of personally identifiable information from your education record. If you agree with the statement, please click “I consent” below. If you do not agree with the statement, please click “I do not consent” below. I consent to the disclosure of any personally identifiable information from my education records to the individual(s)/organizations(s) named below, for reasons determined by Auburn University and Auburn Global as appropriate. I understand that the purpose of the disclosure is to inform the parties listed below of my progress and status at Auburn University, as well as any circumstances affecting my attendance at Auburn University. I understand that my education records may be disclosed to my Parent(s)/Guardian(s) through my Agent/Education Counselor and that my Agent/Education Counselor may only re-disclose education records to my Parent(s)/Guardian(s) identified below. This authorization will remain in effect for the duration of my tenure at Auburn University, but I may revoke the consent by written notice at any time

I consent to the disclosure of any personally identifiable information from my education recordsI do not consent to the disclosure of any personally identifiable information from my education records.

Parent(s)/Guardian(s) 1

First Name:

Last Name

Email Address

Phone Number

Parent(s)/Guardian(s) 2

First Name:

Last Name:

Email Address:

Phone Number:

Financial Sponsor

Name:

Email Address:

Organization:

Phone Number:

Agent/Education Counselor

Name:

Email Address:

Organization:

Phone Number:

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1. Click the "Submit" button below. 
2. Review your information on the form that opens.
3. Add your e-signature and click the "Submit Signed Response" button. 
4. Once you have submitted your e-signature, a verification email will be sent to you. Click the link in the email you receive to complete the submission process. 

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