Ferpa Waiver Form
ADVERTISEMENT
1FERPA WAIVER FORM
11935 Abercorn Street
Savannah, GA 31419
(912) 344-2576
The Family Educational Rights and Privacy Act of 1974 (FERPA) is a Federal law that protects the privacy of student
educational records. When a student reaches the age of 18 or attends a school beyond the high school level, FERPA provides
student confidentiality of information. Armstrong employees will not disclose information from a student record to any
individual without written permission from the student. However, FERPA does allow schools to disclose educational records,
without consent, to school officials with legitimate educational interest and to appropriate parties in connection with financial
aid. By signing this Waiver, the student indicates to whom he/she wants to release information and the type of information to
be released. The completed Waiver form will be kept on file in the Registrar’s Office.
I understand that, in order for Armstrong State University to disclose identifiable information from my educational records to
anyone other than myself, I must provide consent. I understand that I am not required to sign and return this form if I do not
wish consent to be given. I understand that this waiver will remain in effect unless a new waiver is submitted.
I am giving consent for Armstrong State University to either:
1) Disclose any and all education records, OR
2) The following records/information may or may not be disclosed as indicated in the box below:
Only select options in this box if option 2 was selected above.
Disclose
Do not disclose
Disclose
Do not disclose
Attendance Records
Graduation Information
Billing/Student Account information
Schedule
Grades
Other: Please explain below
If “Other” please explain:___________________________________________________________________________
The party or agency to which a disclosure may be made is:
Name(s):
____________________________________________________________________________________________________________________
In order to verify the identity of the recipient of your information, please provide the following:
Recipient’s Date of Birth:________________ and/or Last 4 digits of Recipient’s Social Security Number:____________
Recipient’s Date of Birth:________________ and/or Last 4 digits of Recipient’s Social Security Number:____________
The person to whom disclosure is made must provide identification when requesting information.
______________________________________________________________________________________________________
Student Id Number
Student Name (please print)
Student Signature
________________________
Date of Birth (mm/dd/yyyy)
For this from to be valid, student identity must be verified at signing by an Armstrong employee or a Notary Public.
_________________________________________________________________________________________________________________
STATE OF: Georgia
Official Use Only:
Verified ID
COUNTY OF: Chatham
_____________________________
On the ________ day of ____________________ in the year ________ before me, the undersigned,
Name of Armstrong Employee
personally appeared __________________________, personally known to me or proved to me on the
basis of satisfactory evidence to be the individual(s) whose name(s) is(are) subscribed to the within
_____________________________
instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies),
Initials
Date
and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of
which the individual(s) acted, executed the instrument.
___________________________________
Notary Public
Please complete this form and return to:
Armstrong State University, Registrar’s Office
Registrar’s Office: Updated 7/7/2014
11935 Abercorn Street, Savannah, GA 31419
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal