Student Ferpa Consent
ADVERTISEMENT
1STUDENT FERPA CONSENT TO RELEASE INFORMATION FORM
In compliance with the Family Educational Rights and Privacy Act (FERPA) of 1974 as amended, Washington County Community College (WCCC) will not release
certain information from your student records to a third party, such as information on grades, billing, tuition and fees assessments, financial aid (including
scholarships, grants, work-study, or loan amounts) and other student record information. This restriction applies, but is not limited, to your parents, spouses, or a
sponsor/agency.
You may, at your discretion, grant WCCC permission to release information about your student records to a third party by completing and submitting this form to the
Office of Enrollment Services. Please note that your authorization to release information has no expiration date; however, you may revoke your authorization at any
time by submitting a written request to the same office. Note: for any third party designee you name on this form, this release overrides all FERPA directory
suppression information that you have set up in your student record. WCCC may share Educational Records with those people who claimed you on last year’s income
tax returns, regardless of permissions granted in this form.
STUDENT INFORMATION
Student Name: _____________________________________________ WCCC ID #______________________
Mother’s Maiden Name: __________________________ Student Date of Birth: _______________________
SSN (Last 4 Digits) _________________________
THIRD PARTY INFORMATION
Name: ________________________________________ Relationship: _________________________
Current Mailing Address: ________________________________________________________________
________________________________________________________________
Telephone Number: ____________________________ SSN (Last 4 Digits) _______________________
Record/Purpose of Release:
□ Account/Billing □ Financial Aid □ Academic □ Code of Conduct □ Other: ____________________________
**************************************************************************************************
Name: ________________________________________ Relationship: _________________________
Current Mailing Address: ________________________________________________________________
________________________________________________________________
Telephone Number: ____________________________ SSN (Last 4 Digits) _______________________
Record/Purpose of Release:
□ Account/Billing □ Financial Aid □ Academic □ Code of Conduct □ Other: ____________________________
**************************************************************************************************
Name: ________________________________________ Relationship: _________________________
Current Mailing Address: ________________________________________________________________
________________________________________________________________
Telephone Number: ____________________________ SSN (Last 4 Digits) _______________________
Record/Purpose of Release:
□ Account/Billing □ Financial Aid □ Academic □ Code of Conduct □ Other: ____________________________
**************************************************************************************************
Name: ________________________________________ Relationship: _________________________
Current Mailing Address: ________________________________________________________________
________________________________________________________________
Telephone Number: ____________________________ SSN (Last 4 Digits) _______________________
Record/Purpose of Release:
□ Account/Billing □ Financial Aid □ Academic □ Code of Conduct □ Other: ____________________________
Signature of Student
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal