FERPA consent - 17��Ƶ

FERPA

Date*

Student's Name*

First Last

Student Phone Number*

VBC may call you for confirmation.

Student Email*

Enter Email Confirm Email

Name of Requestor*

(First and last names of person you are giving consent to view your records)

Relationship to Student*

(parent, spouse, prospective employer, attorney, etc.)

Reason for Information Disclosure*

(Please give the reason or reasons for the release of information to the requestor or requestors.)

Student Declaration*

I understand the information may be released orally or in the form of copies of written records.
I understand that this form remains in effect until otherwise revoked in writing by me.
I understand that this form does not cover medical records.
I understand that the purpose of the Family Educational Rights and Privacy Act of 1974 (FERPA) is to protect the privacy of information concerning individual students by placing certain restrictions on the disclosure of “non-directory information” contained in a student’s university records.
I understand that I have the right not to consent to the release of my educational records and I have the right to receive a copy of such records upon request. This act states that a student must authorize in writing the release of his/her educational records.

Signature*

I, the undersigned, hereby authorize 17��Ƶ to release my educational records and information for the purpose of academic advising to the above mentioned requestor. Please type your name indicating agreement.

17����Ƶ

FERPA Agreement

FERPA

17��Ƶ