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Release of Information
I understand that by applying to participate in the VUB Program, I authorize VUB Program staff to obtain re.cords of data pertinent to my VUB participation from other sources as identified and to release information to the United States Department of Education as mandated. The VUB Program staff also has my permission to communicate verbally or otherwise (email, cell phone, texting, etc) with myself, staff, faculty, and/or off-campus professionals on my behalf as identified below.
I understand that all information will be kept confidential and that records will be used for documenting eligibility for the program and for reporting purposes.
Unless written permission is given by you, the student, information maintained in your file will remain confidential and will not be released to a third party or agency. The only exception to this rule is in the clear instance of a legal duty to warn or report, or if your file is legally court
ordered. Please discuss any questions concerning "legal duty" or "court ordered" with program staff prior to signing this form.
Accepted file types: jpg, jpeg, png, gif.
Certification and Approval
I certify that the information provided in the application is accurate and complete. I agree VUB can use
my image in their student database for identification purposes. I agree to use VUB computers for VUB
activities only. Use of printer, copier, or fax equipment must be approved by VUB staff.