Ferpa Release Form - Broward College
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1FERPA RELEASE FORM
The Family Educational Rights and Privacy Act of 1974, also known as FERPA and/or The Buckley Amendment of 1974, as
amended, grants students and eligible parents certain rights and privacies regarding education records of students
attending postsecondary institutions. By submitting this form, the student may consent to release his/her educational
records and/or other information to a third-party for a defined purpose. A new form must be submitted for each
request.
STUDENT INFORMATION (Please print):
_________________________
___________________________
________________________
LAST NAME
FIRST NAME
STUDENT ID NUMBER
_________________________
___________________________
PHONE NUMBER
EMAIL ADDRESS
This release/disclosure may be made to (identify the party or class of parties). Please print the name of the party or
parties below:
CHECK () TYPES OF EDUCATION INFORMATION TO RELEASE
Check
Name
Description
()
Academic Grades
Grades earned in courses (tests, quizzes, assignments, projects) during the course of the
semester.
Academic Records
Includes all grades for courses including: , GPA, credits earned, credits attempted, and
degree(s) awarded included on the student’s transcript record.
Financial Aid
Includes financial aid information (Pell eligibility, EFC, AGI (adjusted gross income) and other
determining factors related to Federal student aid eligibility as this relates to determination
of eligibility for financial and other support provided a third-party agency
Accounting
Includes tuition and fee balances, financial holds, mailing and billing address, payment plans,
accounting statements, collections and debt information
Registration
Includes information and documents related to current enrollment, dates of enrollment
activity, enrollment status, residency status, semesters attended and mailing address
information
General Information
Non-directory contact information
Disciplinary Records
Includes information related to College discipline matters.
Cancel Previous Release
Cancels any previous request
I hereby release Broward College, its Trustees, Officers, and Employees, including the College Registrar, Agents or Assigns, from any
and all liability for release of the above named records/information. This authorization is valid until canceled. The student may
cancel this release at any time by submitting another FERPA form to the Broward College Office of the Registrar.
_______________________________________________
___________________
STUDENT SIGNATURE
DATE
Office of the Registrar / 225 E Las Olas Blvd., Fort Lauderdale, FL 33301 / Telephone 954-201-7471/
ferpa@broward.edu
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