Looking for a Consent To Release Information Form Templates? Download it for free!

Verification and Certification

TIDEWATER

COMMUNITY COLLEGE

Release of Information

From here, go anywhere.

The Family Education Rights and Privacy Act of 1974 (FERPA), amended, 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.

Print full name ________________________________________ Former name(s)_____________________________________

Birthdate (dd/mm/yy) ________________________SSN#* _______________________SIS ID ___________________________

*Social Security Number not required, but highly recommended for students whose last attendance was 2003 or earlier, so that the record can be

located more efficiently.

In processing your request, TCC may need to furnish and/or confirm your Social Security Number (SSN) with the third party that you have speci-

fied. Per the Federal Educational Rights and Privacy Act (FERPA), you have the right to authorize or prevent disclosure/confirmation of your SSN

to most third parties. As such, please indicate below whether TCC is authorized to release your SSN if requested and/or needed in processing this

request.

❑ I authorize TCC to disclose/confirm my SSN if requested and/or needed in processing this request

❑ I do not authorize TCC to disclose/confirm my SSN if requested and/or needed in processing this request

(NOTE: In some instances, TCC may be lawfully required to disclose a student SSN)

1. The record(s) to be disclosed is (are):

❑ Information from your TCC Application for Admission form

❑ Permanent record (grades, GPA, degrees, etc.)

❑ Student Accounts

❑ Financial Aid

❑ Other (describe: i.e., estimated completion date, previous graduation, etc.)

______________________________________________________________________

2. The purpose(s) of disclosure is (are):

❑ Certify current enrollment at Tidewater Community College

❑ College level (credit/unit)

❑ Full-time (12 or more credit hours)

❑ Part-time (less than 12 credit hours)

❑ Certify past enrollment at Tidewater Community College

❑ Defer payment to ________________________________________________________

❑ Other (describe) _________________________________________________________

3. The person or organization to whom this disclosure is to be made:

Name of party ___________________________________________________________

Address of party __________________________________________________________________________

Fax number of party __________________________________________________________

❑ Hold for student pick up of requested information

❑ Mail requested information

❑ Fax requested information

Return Completed Form to Enrollment Services:

Chesapeake Campus

Norfolk Campus

Portsmouth Campus

Virginia Beach Campus

Pass Building, Rm. 175

Andrews Building

A Building

Bayside Building

1428 Cedar Road

300 Granby Street

120 Campus Drive

1700 College Crescent

Chesapeake VA, 23322

Norfolk VA, 23510

Portsmouth VA, 23701

Virginia Beach VA, 23453

Signature of student (Authorization to release)_______________________________________________ Date________________________

Campus of Record _______________________________________ Telephone number (contact or message #)_________________________

Office Use Only

Processed by: __________________________________ Date/Time Contacted Student: _________________

10/15

Verification And Certification Release Of Information Form - Tidewater Community College

Related Articles

Related forms

Related Categories