FERPA: Authorization for Release of Information

FERPA: Authorization for Release of Information

COM Cohort*

Select

Student Number

Full Name*

Date of Birth*

Release*

FULL ACCESS. Consent for Full Access to education records (Please note: Full Access does not give authority to make changes to the student's education record)

LIMITED ACCESS. Consent to Limited Access to education records. (Please note: Limited Access does not give authority to make changes to the student's education record)

LIMITED ACCESS

Academic Information. (grades/GPA, registration, academic progress, enrollment status, etc)

Financial Aid Information (awards, application data, disbursements, eligibility, financial aid academic progress status)

Student Account Information (billing statements, charges, credits, payments, past due amounts, collection activitiy)

Other (please specify)

Other

Release to:*

Please list the name, address (street, city, state, zip) and phone number of the person receiving the information.

Relationship to Student*

5-digit PIN Number*

Please provide a 5-digit PIN number. The person that will be receiving the information must have access to the PIN number. The Office of the Registrar will not release information without the PIN.

Valid For*

During the Time Period: (list start date and end date below)

One Time Use: This authorization can only be used once on (please specify below)

Limited Use: This authorization expires on (please specify below)

Long Term Use: This authorization will remain in effect until I withdraw this authorization in writing.

Start Date

End Date

One Time Use

Please list the details of the one time use. Example: Can only be used for Fall 2021 grades.

Limited Use Expiration Date

I understand that some of my records may be protected under the Family Educational Right and Privacy Act of 1974 and cannot be released without my written consent. I hereby waive all provisions of the law and privilege relating to the records described in this disclosure. I certify that this consent has been given freely and voluntarily. I may revoke this consent at any time by providing written notice of such revocation to the Office of the Registrar.

I AFFIRM the statement above.*

Send me a copy of my responses

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