Ferpa Consent To Release Educational Records printable pdf download

FERPA Consent to Release Educational Records

The Family Education Rights and Privacy Act of 1974 (FERPA) states that a student must authorize in writing the

release of her or his educational records to a third party. Please print legibly in ink when completing this form.

Student ID: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date of Birth: _ _ _ _ _ _ _ _ _

Person(s) to whom you authorize the release of your r e c o r d s : - - - - - - - - - - - - - - - -

You can list multiple people. You must provide each authorized person listed with the password you choose below.

If they are

unable to provide the password, your records cannot be released.

Password:

------------------------------------

You are responsible for the security of this password. Protect it from unauthorized parties.

I authorize the release of educational records in the following areas (check all that apply):

Academic Records

Financial Aid

Student Accounts

Select the duration for which you authorize the release of your educational records. Granting access to the

parties listed does not preclude you from revoking access to any of the parties or record types above, if done so in writing.

Grant continuous access for the duration of my academic career

I do not wish to grant continuous access. Access should end

on__}__} _ _ .

Month

Day

Year

I realize that if I choose to limit access no information will be shared with the people listed above after

the date I select. Access can only be reinstated by completing a subsequent

FERPA Consent to Release

Educational Records

form.

Student S i g n a t u r e : - - - - - - - - - - - - - - - - - - - - - - Date: _ _ _ _ _ _ _ _

Form must be submitted in person at the office below, along with a picture ID. Otherwise a Notary signature is required.

I am not submitting my form in person. My notary verification is below.

Notary: _______________________ Commission Exp: _______ _

Return Completed Form to: PDCCC Financial Aid Office

1-855-877-3918

FinancialAid@pdc.edu

or Admissions Office** 100 North College Drive, Franklin, VA 23851 ** 271 Kenyon Road, Suffolk, VA 23434 **

Office Use Only

Person who entered authorization into SIS:

----~~---------Date

entered: _ _ _ _ _ _ _ _

Routed to:

Admissions

Financial Aid

Business Office

Ferpa Consent To Release Educational Records