REFERENCE REQUEST  
AND  
STUDENT AUTHORIZATION FOR RELEASE OF INFORMATION

Winona State University  
Department of Health and Human Performance

I, (print name) ___________________________________________________ request

WSU Health, Exercise, and Rehabilitative Sciences Faculty/Staff (name of person providing

reference/releasing information)________________________________ to serve as a

reference or release information for me. The purpose(s) of the reference(s)/release of

information is(are) for: (check all that apply)

________ application for employment

________ all forms of scholarship or honorary award(s)

________ other (please specify) ______________________________________

The information may be given in the following manner: (check all that apply)

               _____ written            _______ oral             _______ electronic

I authorize the above named person to release information and provide an evaluation about any and all aspects of my academic performance at Winona State University to the following: (check all that apply)

_______all prospective employers              OR              _______specific employers (list on back)

_______all organizations considering          OR              _______ specific educational institutions

                me for a scholarship or                                            considering me for a scholarship

                 award(s) (including release                                           or award(s) (list on back)

                 of my social security number for

                 issuance of scholarship check)

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 above on this form.

If you waive your right of access, the waiver remains valid indefinitely unless a termination date is specified as follows: (termination date) __________________________________________.

Signature:_____________________________________     Date:_______________________