Ferpa Form - Averett University printable pdf download

FERPA AUTHORIZATION

RELEASE INFORMATION FORM

The Family Educational Rights and Privacy Act (FERPA) of 1974 is designed to protect the privacy of a student’s educational records. These

confidential records may include, but are not limited to, university records, financial aid, scholarship and fellowship, and student account/billing

information. The Information will not be released to anyone other than the student without written consent from the student. By signing this form,

the student authorizes university personnel to release the Information to the designated person(s).

I authorize university personnel to discuss information for the purposes of understanding and meeting university related records and

financial obligations with me (the student) as well as the person(s) listed on this form. I understand that the person(s) listed on this

form will have access via telephone, in person, mail, e-mail, or fax to the Information that may include the following:



My financial aid and scholarship records, including processing and eligibility status as well as award types and amounts. This

information will not include specific parental income or asset information.



My university tuition billing account and statements, including credits and debits posted to that account and any refund

amounts I may have received.



My university Housing, Dining, Bookstore and any other financial obligations, which may include amounts owed as well as

amounts paid.



I, the undersigned, hereby authorize Averett University to release the following educational records and information:

Attendance

GPA

ALL records and information

Course Participation Information

Grades

Disciplinary Action

Transcripts

Enrollment Verification

Schedule

Student Name:

Student ID No.: P000

Social Security No:

*Security Word

List of person(s) to whom I am granting authorization to receive the above mentioned Information from representatives of Averett

University:

Name

Relationship

Address

Daytime/Cell Phone

Name

Relationship

Address

Daytime/Cell Phone

Name

Relationship

Address

Daytime/Cell Phone

I understand that this authorization will be effective today and this authorization will remain in effect until a new authorization form is

received from the student. To add, delete or change authorized persons, you MUST complete a new form.

Student Signature:

Date:_________________

*In order for your record information to be released over the phone to a third party, you must create a Security Word and share this word with the

third party caller. The third party may be asked to confirm the Security Word before your record information will be released over the phone.

PLEASE PRINT, FILL OUT THIS FORM, AND RETURN TO AVERETT CENTRAL OR FAX 434-791-5647

RETAIN A COPY FOR YOUR

RECORDS.

SFS /Registrar 3/3/2016

Ferpa Form - Averett University

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