Ferpa Student Education Record Release Form - Dominican College

FERPA

Student Education Record Release Form

I, ________________________________________________________________, Student ID # _____________________

(Student Name – PRINT CLEARLY)

By signing this form I hereby give permission to Dominican College to discuss my

Education and Financial records with the following individual(s):

NAME

RELATIONSHIP

Note: This consent does not cover medical records which are held by the Student Health Office.

I can be claimed as a dependent on my parent’s tax return

The information will be released with my FULL CONSENT. I understand this release authorization

remains in effect until I submit a written request to revoke it.

__________________________________________________________

________________________

STUDENT SIGNATURE

DATE

Please return the completed form to the Registrar’s Office

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Parent category: Legal