Student Reference Request Consent Sample Form
Student name (print): _______________________________
I request ____________________ to serve as a reference for me. The purpose(s)
of the reference are: (check all applicable spaces)
_____ application for employment
_____ all forms of scholarship or honorary award
_____ admission to another education institution
The reference may be given in the following form/s (check one or both spaces):
_____ written
_____ oral
I authorize the above person to release information and provide an evaluation
about any and all aspects of my academic and/or employment performance at the
University of Minnesota Duluth to the following (check all applicable spaces):
| 1. |
_____ all prospective employers |
OR |
_____ specific employers (list on reverse side) |
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| 2. |
_____ all educational institutions to which I seek admission |
OR |
_____ specific educational institutions (list on reverse side) |
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| 3. |
_____ all organizations considering me for an award or scholarship |
OR |
_____ specific organizations (list on reverse side) |
This authorization to provide references is valid for one (1) year from the
date of my signature below, unless I specify an earlier ending date as follows:
Ending date: ___________________________
Note: Under the Family Educational and Privacy Rights Act, 20 U.S. C. 1232(g),
you may, but are not required to, waive your right of access to confidential
references given for any of the purposes listed on this form above. If you waive
your right of access, the waiver remains valid indefinitely.
___I waive my right of access
| __________________________ |
__________________________ |
| Signature |
Date |