Student Consent Form

PLEASE READ THE FOLLOWING CAREFULLY AND ENSURE THAT YOU UNDERSTAND THE CONTENTS THEREOF:

I know that the Protection of Personal Information Act, 2013 as amended protects the privacy of my student educational records and limits access to the information contained in those records.

Student ID

Name

Class

Campus

I understand that I am giving permission to the individual(s) and/or company representatives listed below to have access to my educational records:

1.

Name

Address

E-mail

Telephone

Relationship to student

1.
Name
Address
E-mail
Telephone
Relationship to student

2.

Name

Address

E-mail

Telephone

Relationship to student

2.
Name
Address
E-mail
Telephone
Relationship to student

By signing this form, I authorize the above named individual(s) and/or company representatives to be informed about the following information (check all those that apply):

Yes	No	Type of consent

		my grades and academic standing
		my enrolment records
		my financial aid information
		my billing records
		my disciplinary records
		Specific personal information (e.g. as discussed with the student counsellor):

		I am choosing not to share information with my parent or guardian

I understand that I am under no obligation to sign this consent form and that I may revoke consent at any time, in writing. The consent will be valid from the date of signature (or date of form submission if done digitally) until the admin office received written notification of the cancellation.

Click here to sign	Date Signed

I hereby confirm the consent settings indicated above:

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By submitting this form, I verify that the information herein is true, complete and accurate. Moreover, I understand that Belgium Campus will not be held liable for any wrong or inaccurate information provided.