Third-Party Authorization Form (TPAF)

ACADEMIC HEADQUARTERS
Office of the Registrar
550 West Van Buren, 7th Floor
Chicago, IL 60607
Third-Party Authorization Form (TPAF)
OVERVIEW
Students who have attended a Kaplan Higher Education institution may authorize the release of non-directory, personal information to
another individual(s) by submitting this Third-Party Authorization Form. Third-Party Authorization does not act as, or take the place of
Power of Attorney. In addition, Kaplan Higher Education reserves the right to revoke the Third-Party Authorization at any time.
INSTRUCTIONS
To grant access to your information to designated individual(s) or to revoke previously-granted access, complete the appropriate fields
below, print, sign, date, and submit this form to the appropriate Office of the Registrar. Note that authorized parties will be required to
verify their identity when speaking to Kaplan Higher Education staff about your records by providing their name, their relationship to
you, their phone number, and the last 4 digits of your SSN. Be advised that processing this form may take up to 6-8 business days from
the date of receipt. Incomplete forms will not be processed.
Please complete and email this form to [email protected] or fax it to 800.882.9519.
STUDENT INFORMATION
Student Name: ___________________________________________________ Student ID or last 4 digits of SSN: _________________________
Name of College/School PREVIOUSLY Attended: ________________________________________________________________________________
City: ________________________________________________________ STATE: _________________________________________________________
Email Address: ______________________________________________________________________________________________________________
Reason for RELEASE of information: _____________________________________________________________________________________
THIRD PARTY
Third Party
Name
(First and last name of contact required)
Place an X in ONE of the columns
below for each individual listed.
Relationship to Student
Phone Number
I grant this person
access to my records.
I withdraw
permission for this
person to access my
records.
I choose to share the following types of records with authorized individual(s) (check only ONE):
___ All Records
___ Academic Records Only
___ Financial Records Only
This authorization is valid until (specific expiration day, month, and year required): __________________
I authorize and/or withdraw, as noted above, permission for the above individual(s) indicated to access my student record. My information
may be released to any person(s) granted access above from this date until the expiration date specified above, unless revoked earlier
by me via submission of an additional Third-Party Authorization form. I acknowledge that this Third-Party Authorization form allows
permission for Kaplan Higher Education to share information only; it does not allow the above authorized parties to make decisions my
behalf. I acknowledge that Kaplan Higher Education may revoke third-party authorization at any time.
___________________________________________________________
________________________________________________
Student Signature Date
TPAF KHE Rev 12/2015