Ferpa Waiver Form printable pdf download

FerPA WAiver Form

instructions:

This form is to be used by the student to grant access to their records to other persons or entities, such as a parent, spouse, or

employer. When completing this form, please print all items clearly to allow for correct processing. If this form is mailed or faxed, an

enlarged copy of your official government issued ID, with a signature, is required.

Student information

Last Name ______________________________________ First Name _________________________Middle Initial ________________________

Mailing Address ________________________________________________________________________________________________________

Phone No. ___________________________________ Email Address _____________________________________________________________

I give permission to the College to release the type of information selected below to the recipient listed below:

Types of Information to Release

___ All Records

___ Accounting Includes tuition and fee balances, financial holds, mailing and billing address, payment plans, accounting statements

and collections and debt information.

___ Admission Includes dates of application, programs selected, documents received, documents pending, dates of admission,

admission status and conditions of admission.

___ Registration Includes current enrollment, dates of enrollment activity, enrollment status, residency status, semesters attended and

mailing address information.

___ Academic Records Includes courses taken, grades received, GPA, academic progress, honors, transfer credit awarded and

degree(s) awarded.

___ Financial Aid Includes all general financial aid information.

Full Name of Person authorized for these records ___________________________________________________________________________

Relation __________________________________________________

***PLEASE NOTE***

Records protected under FERPA will not be released without a properly completed and executed form. The person) or entity identified in

this release will be required to provide proof of identity before records or information will be released to them. No information will be released

via telephone.

I understand that this request is will remain in effect until I request in writing that the permission(s) be removed or revised.

Student name _______________________________________ Student signature _________________________________________________

date _________________________________________________________________

For the registrar’s office use only

Processed by: _________________________________________________ Date: _________________________________________________

please return this form to the registrar’s office.

Southerntech

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Ferpa Waiver Form