Student Consent Form To Release Information
Download a blank fillable Student Consent Form To Release Information in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Student Consent Form To Release Information with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1STUDENT CONSENT FORM TO RELEASE INFORMATION
Family Educational Rights and Privacy Act (FERPA) of 1974
20 USC § 1232g and 34 CFR § 99
Instructions to Student: Carefully read the information below. After completing the form,
submit it to the LATTC faculty/staff/office you authorized to release your information.
In accordance with the Family Educational Rights and Privacy Act (FERPA) of 1974, LATTC must
obtain written consent from a student before releasing the educational records of that student to a third
party. Such written consent must be signed and dated by the student, specify the records to be released,
state the purpose of the release, and identify the party or class of parties to who release may be made.
I ___________________________________________________ , ________ - _______ - ________
(Student’s Name-Print)
(Student ID #)
hereby give my written consent to____________________________________________________
(LATTC Faculty/Staff/Office)
to release my _____________________________________________________________________
(Specify records to be released)
to _______________________________________________________________________________
(Identify the person(s) to whom release may be made)
for the purpose of _________________________________________________________________.
(State the purpose of the release)
I understand that the information will only be released over the telephone to my authorized third party
when s/he provides the LATTC staff member authorized to release the information with the following
password: _____________________________________________________. (Write password here)
I understand that my written consent will remain in effect until I notify the LATTC employee/office
named in this form, in writing, to cancel it.
I understand that the specific information referenced on this form is being released to a third party at my
request with the understanding that s/he will not release it to any other parties. LATTC is hereby released
from all legal responsibility or liability for the release of the above-mentioned information.
Student’s Signature: _________________________________________ Date: ___________________
LATTC is required to keep the original signed consent form. Students are advised to keep a copy of
this consent form with their records.
For Registration Office Use Only: Receipt Date __________________ Staff Initial ________ __________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal