Ferpa Form - Student Consent To Release Academic Information printable pdf download

FERPA

NOTICE: This information is being provided to you to clarify questions regarding your

rights under the Family Educational Rights and Privacy Act (FERPA). For the purposes

of FERPA and this form, “educational records” include academic progress reports, other

academic information (such as academic probation letters), and disciplinary records (such

as behavioral or chapel probation). If you are claimed as a dependent on your parents’

Federal Income Tax return, your parents are entitled to the above information. If you are

not a dependent of your parents, providing them this information is your choice. The

purpose of this form is to provide your educational records as much protection as

possible.

STUDENT CONSENT TO RELEASE ACADEMIC INFORMATION

Name _______________________________________ Class ____________________

Student ID #__________________________________ Major ____________________

Parent name and address:

Parent at another address:

____________________________________________ __________________________

LIPSCOMB UNIVERSITY is subject to the provisions of the Family Educational Rights

and Privacy Act (FERPA) that affords to students certain rights of access to educational

records and imposes obligations on the university in the release and disclosure of those

records to third parties. FERPA regulations, however, allow the university to provide

academic progress reports, other academic information, and disciplinary information to

your parents if you are your parents’ dependent for federal income tax purposes.

In order to improve the university’s records and to administer properly the release of this

information to your parents, the university requests that you complete this form. The

information will be sent to your parents at the address shown above. If we have not listed

the name and address of another parent who should receive information, please indicate

in the space provided above.

____

I am a dependent of my parents.

____

I am not a dependent of my parents, but I consent to the release of academic

information to my parents.

____

I am not a dependent of my parents, and I do not consent to the release of

academic information to my parents.

_______________________________________

________________________

Student’s signature

Date

Revised 6/27/2011

Ferpa Form - Student Consent To Release Academic Information