Student Consent Form For Release Of Confidential Information

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Student Consent Form for Release of Confidential
Information
University of Wisconsin – Stout
University Housing
I, _______________________ authorize ______________________________ to
(Name of Student)
(Name of Staff Member)
release the following information
: (examples of things that you may want to exclude:
sexual orientation, specific conduct information, academic status, information resulting from a
sexual assault, etc.)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
to
1. _______________________________
2. _______________________________
3. _______________________________
4. _______________________________
5. _______________________________
(Name(s) of People or Organizations)
By signing below, I acknowledge that I understand that my confidential
information is protected under federal regulations governing The Family
Educational Rights and Privacy Act (FERPA) and cannot be disclosed without my
written consent unless otherwise provided for in the regulations. I also
understand that I may revoke this consent at any time in writing.
_________________________________________________________________
(Student Signature)
(Date)
_________________________________
(Student Name Printed)
_________________________________________________________________
(Staff Signature)
(Date)
__________________________________
(Staff Name Printed)

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