Ferpa Consent College Of Health And Human Services, Uncw
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1FERPA CONSENT
College of Health and Human Services, UNCW
Request to Release Personally Identifiable and Confidential
Information from Educational Records
Student Name: ___________________________________ Student ID: ________________
Last
First
MI
The Family Educational Rights and Privacy Act (FERPA) protects the privacy of students’
educational records. Educational records include grades, academic status, and class schedule.
Students may voluntarily and temporarily waive their privacy rights to the person(s) identified in
the statement below. By completing this form, the student grants the named person(s) access to
information in the student’s educational records.
I hereby authorize the College of Health and Human Services to release educational records to:
__________________________________________________________________
(First name, last name and relationship of the person[s] authorized to obtain information.) Please print legibly.
In order to ensure your privacy is maintained, we will be
(Privacy Question) (Example: What is my dog’s name?)
___________________________________
(Answer) (Example: Fido)
We will ask this question of anyone who calls to discuss your personal information. Please share
this question and answer with anyone you wish to have access to your information.
I understand that
(1) I have the right not to consent to the release of my educational records;
(2) I have the right to receive a copy of such records upon request;
(3) This consent shall remain in effect, unless revoke by me;
(4) I may revoke this consent at any time. Any such revocation shall not affect
disclosures previously made by UNCW prior to the receipt of any such written
revocation.
Student’s Signature: __________________________________
Date: ____________
Form: FERPA Release
Print Form
Clear Form
Revised:
Return completed form to the CHHS Student Success Center, McNeill Hall, Room 1011.
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