Authority to Release Information Form

Authority to Release Information Form

Instructions

Learners who are/were enrolled in an AIE course can use this form to allow AIE to communicate openly with their nominated delegate(s) about any relevant course information as described below. Please complete all fields necessary to ensure AIE has the most up-to-date details.

Upon submission of this form, the learner receives a PDF of the form for their records. A copy of the PDF is also automatically sent to AIE Administration of the learner's campus.

Authority to Release Information

Learner or Alumni Name*

First Name

Last Name

Learner or Alumni Email*

An exported PDF with your answers will be sent to this email after this online form is submitted.

Learner or Alumni Campus*

Information AIE is Authorised to Release*

General information about my course progress Specific information related to assessments Specific information in relation to attendance Specific information in relation to fees and payments

Other:

Please check all that apply.

Delegate Details

Delegate One

Delegate One Name*

First Name

Last Name

Delegate One Relationship to Me*

Delegate One Phone Number*

Delegate One Email Address*

I have an optional second delegate.*

Yes No

Delegate Two (Optional)

Delegate Two Name (Optional)*

First Name

Last Name

Delegate Two Relationship to Me (Optional)*

Delegate Two Phone Number (Optional)*

Delegate Two Email Address (Optional)*

Signature

Learner or Alumni Signature*

[clear]

Use your mouse or finger to draw your signature above

Date*