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
I, the undersigned, hereby authorize Averett University to release the following educational records and information:
ALL records and information
Course Participation Information
Student ID No.: P000
Social Security No:
List of person(s) to whom I am granting authorization to receive the above mentioned Information from representatives of Averett
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.
*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
SFS /Registrar 3/3/2016