Student Records Release/Review Authorization Form

Student Records Release/Review Authorization Form

In compliance with the federal Family Education Rights and Privacy Act of 1974, Foothill College is prohibited from providing certain information from your student records to a third party, such as information regarding grades, billing, tuition and fees assessment, financial aid (including scholarship, grants, work-study, or loans) and other student record information. This restriction applies, but is not limited, to your parents/guardian, spouse, or sponsor.

Foothill College may, however, disclose certain types of directory information under Foothill-De Anza district Board Policy 5050, the college may disclose the following directory information unless a student files a written request to withhold it:

You may at your discretion, grant Foothill College permission to release information about your student record information to a third party by submitting a complete Student Record Release Authorization form. You must complete a separate form for each third party to whom you grant or withhold access. The specified information will be made available only if requested by the authorized third party. Foothill College will not automatically send information to a third party.

Student Information

Student Last Name*

Student First Name*

Student College Identification Number*

Student Email Address*

Release Options*

Plese select one of the following options:

ALLOW release of my student record for self-review

ALLOW release of my student record information to the individual indicated on this form

WITHHOLD release of my directory information & student record information to the following individual

WITHHOLD release of my directory information & student record information to anyone but me

Third-party Designee Information

Name*

First & Last

Relation to Student or Agency*

Address*

Street, City, State, Zip

Phone Number*

Phone

Email Address*

Information Types Allowed

Select all information you will to review, release or withhold

Information Selection*

Grades, GPA, demographic, registration, registration hold, Academic Progress status, enrollment information

Billing statements, charges, credits, payments, past due amounts, collections activity

Financial aid awards, application data, disbursement, eligibility, financial aid satisfactory academic progress

Disciplinary, Title IX, Student Code of Conduct information, records related to incidents addressed in Foothill Community College policy

Student Certification

Student Signature*

By typing my First and Last name I give consent to Foothill Community College to release/withhold my student information to the third party designee listed above.

This form will be kept on permanent file until I revoke it at any time by submitting a written request. This authorization does not permit the listed party to make any changes to my student records.

Photo Identification*

Attach a picture of any form of photo identification (driver's license, passport, student ID, etc.)

Drag and drop files here or

Send me a copy of my responses

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