FERPA Consent to Release Student Information Form

FERPA Consent to Release Student Information Form

The FERPA consent to release student information form is a document that obtains the student’s permission for someone else (ie: student transfer, parent(s), prospective employer etc.) to allow the college or University to release the student records to person(s) named within the contents of the document. By provision of this document, the student is granting permission for the records to be released in written or oral form.

This document will not allow a medical record release. In order to obtain medical records on behalf of a student, the student would have to provide a separate consent form, from the student and Student Medical Services.

The student may revoke the document at any time by providing written permission to the institutions records department who shall, in turn, ensure that the request is immediately forwarded to the proper channels.

How to Write

Step 1 – Download in Adobe PDF (.pdf).

Step 2 – Once the student has downloaded the document they may begin by entering:

  • The name of the individual (and their department) who shall release the student’s records
  • Enter the student’s name
  • Submit the name of the person(s) to whom permission shall be granted by the student to receive the records in any form (no campus medical records will be released without a separate consent for that department)
  • Check one or any of the records to be released ( if “other,” specify)
  • Check the purpose for which the student is releasing records (if “other,” specify)

Step 3 – Signature –

  • Once the form has been completed, the student must carefully review the last statement (paragraph) If in agreement, enter the following:
  • Student’s printed name
  • Student’s signature
  • The student’s identification number
  • Enter the date of the signature in mm/dd/yyyy format

The student should request a copy of this permission to release their records for their private record keeping.