Post SecondaryEducation

LONG PLAIN FIRST NATIONTREATY ONE 287(35)POST SECONDARY DEPARTMENT

AUTHORIZATION FOR RELEASE OF STUDENT INFORMATION

IMPORTANT - INCOMPLETE FORMS WILL BE RETURNED. PLEASE PROVIDE THE CORRECT USERCODE &PASSWORD. FAILURE TO DO SO WILL RESULT IN THE DISCONTINUATION OF FUNDING. PLEASE PRINTCLEARLY. DROP OFF OR MAIL THIS FORM TO THE ADDRESS BELOW.THIS OFFICE WILL ONLY ACCEPT THE ORIGINAL SIGNED COPIES.

Post Secondary Institution:

Name ofProgram

AcademicYear/Session:

User Code: PIN:

Date:DAY MONTH YYYY

Student Name:

Date:DAY MONTH YYYY DAY MONTH YYYYExpected Graduation

(Date)

Student Signature:

Student ID#:

PLEASE NOTIFY THE LPFN POST-SECONDARY PROGRAM IF YOU HAVE CHANGED YOUR PASSWORD.

ONLINE ACCESS

I hereby give permission to the above-named institution to release my sponsoring agencies any and all records that pertain to educational matter. Please send reports to the address in the box.

LPFN Post-Secondary Department110-5010 Crescent Road W.

Keeshkeemaquah, MBR1N 4B1

“As long as the sun shines, the river flows and the grass grows...”

LONG PLAIN FIRST NATION110-5010 Crescent Road West, MB R1N 4B1

Phone: (204) 857-7474

Fax: (204) 857-7480Email: jdaniels@lpet.caWebsite: www.lpet.ca