Ferpa Waiver Request printable pdf download

FERPA Waiver Request

Office of the Registrar

The Family Educational Rights and Privacy Act of 1974 (FERPA) obligates a college or university to maintain

the confidentiality of educational records. These records include, but are not limited to, academic information

such as grades, grade point averages, course schedules, and academic standing, which are maintained by the

Office of the Registrar. Official transcripts will be released only upon the written authorization by the student

and there is a charge for that service; unofficial transcripts are available on the My CHC Portal.

Students who wish to authorize release of their academic information to parents, guardians, spouses or any

other individual may do so by signing the Waiver below and submitting it to the Office of the Registrar, 3

Floor of St. Joseph Hall. By signing this form, the student is waiving his/her rights under the Family Education

Rights and Privacy Act and is asking that grades, grade point averages, course schedules, or academic

standing be released to the named person(s) indicated on the waiver. The requested information will be

released to the named person(s), either by mail or in person with photo identification, when the named

person makes a written request for the information. Absolutely no non-directory academic information

(e.g., grades and/or grade point average) will be released by phone, fax, or email whether or not a waiver

is submitted.

Directory information may be released to those requesting such information unless the student has

specifically requested that the information be restricted. Directory information consists of name, addresses,

telephone numbers, date and place of birth, program concentration(s) and minor(s), student activities,

including athletics, dates of attendance, degrees and awards, rate of graduation, most recent previous school

attended, academic awards/scholarships, number of credits (full- or part-time) for which a student is

registered. If you wish to restrict the release of designated directory information, please come to the Office of

the Registrar, 3

Floor of St. Joseph Hall for assistance.

STUDENT WAIVER

Name of Student: ____________________________________________________________ ID# ___________________

I hereby waive my rights under the Family Educational Rights and Privacy Act of 1974 (FERPA) and I grant

permission for Chestnut Hill College to release academic information upon receipt of written request from

the following:

1/ Name: ______________________________________________________ Relationship: ____________________________

Telephone: _______________________________________

Email: ______________________________________________________

2/ Name: ______________________________________________________ Relationship: ____________________________

Telephone: _______________________________________

Email: ______________________________________________________

Signature: ____________________________________________________________ Date: _______________________

This waiver will remain in effect for the student’s entire academic career, or until rescinded in writing.

Academic information (e.g., grades and/or grade point average) will be released to any individual named above, either in person (with photo ID)

if the individual meets with a College staff member, or by mail, after the individual submits a written request.

Revised 07/18/2011 DE

Ferpa Waiver Request