Student Privacy FERPA Form

Student Privacy FERPA Form

Student Name:

Date of Birth:

Parent / Guardian (if student is a minor)

Authorization to Release Education Records

I hereby authorize the school named above to disclose the student education records identified below to the recipient designated in this form. I understand that such disclosure is made for the specific purpose stated and that the recipient may re-disclose the information unless otherwise restricted by law.

Records and Information Authorized for Release (check all that apply)

Academic records (grades, course enrollments, progress reports)

Official and unofficial transcripts

Attendance records

Disciplinary records

Health or medical records maintained by the school (if applicable)

Financial records (tuition, billing, student account)

Directory Information Release

Directory information may include: student name, address, telephone number, electronic mail address, photograph, dates of attendance, degrees and awards received. Check one option:

I AUTHORIZE release of directory information as described above.

I DO NOT AUTHORIZE release of any directory information.

Duration, Revocation, and Conditions

Unless a different expiration date is specified below, this authorization will remain in effect until revoked in writing. I understand that a written revocation will not affect disclosures already made in reliance on this authorization prior to receipt of such revocation by the school. This authorization will not be valid if required signatures are missing or if the purpose is unlawful.

Expiration Date (if not revoked earlier):

Revocation: To revoke this authorization, deliver a signed and dated written notice to the school office. Revocation becomes effective upon receipt but will not apply to disclosures made prior to receipt.

Certification and Signature

I certify that I am the eligible student (age 18 or older) or the parent or legal guardian of the student named above and have the authority to sign this authorization. I acknowledge that I have read and understand my rights under the Family Educational Rights and Privacy Act, including the right to inspect disclosed records and to refuse to consent to disclosure, except as otherwise permitted by law.

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