Authorization To Release (Ferpa) Student Account And/or Financial Aid Information

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CLEAR

AUTHORIZATION TO RELEASE (FERPA)

STUDENT ACCOUNT and/or FINANCIAL AID INFORMATION

RETURN TO:

Last Name:

CAL POLY STUDENT ACCOUNTS OFFICE

ADMIN 211

SAN LUIS OBISPO, CA 93407-0201

FAX: (805) 756-2774

First Name:

EMAIL:studentaccounts@calpoly.edu

-OR-

CAL POLY FINANCIAL AID OFFICE

Phone #

ADMIN 212

SAN LUIS OBISPO, CA 93407-0201

FAX: (805) 756-7243

EMPL ID#:

EMAIL:

financialaid@calpoly.edu

CHECK ONE BOX ONLY

I hereby authorize and request California Polytechnic State University, San Luis Obispo, to discuss all

information relating to my student account and financial aid as indicated in the statements below, with the

individual(s) named in this document.

I hereby authorize and request California Polytechnic State University, San Luis Obispo, to discuss all

information relating ONLY to my student account (institutional charges including Extended Education

charges, financial aid credits and disbursements, payment, etc) with the individual(s) named in this document.

I hereby authorize and request California Polytechnic State University, San Luis Obispo, to discuss all

information relating ONLY to my financial aid (eligibility and awards) with the individual(s) named in this

document.

PLEASE PRINT

Name _______________________________________

Relationship _________________________________

Date of Birth ________________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Name _______________________________________

Relationship _________________________________

Date of Birth _________________________________

In the event damages should occur due to the release of such information, the undersigned agrees to hold California

Polytechnic State University, San Luis Obispo, harmless.

A copy of this authorization is as valid as the original. No electronic signatures accepted.

This document will remain in effect until revoked by the student in writing.

Student Name (Print) ___________________________________________________________________________

Student Signature ______________________________________________ Date __________________________

FFERPA