Education Records Information Disclosure Form - Revocation Of Authorization printable pdf download

UMKC RESIDENTIAL LIFE GENERAL FERPA RELEASE FOR DISCLOSURE

OF STUDENT EDUCATION RECORDS

Name of Student: _________________________________________

Date: ______________

Date of Birth: ________________________

Student ID Number: ______________________

I, the undersigned student, hereby grant permission and authorize the University of Missouri – Kansas

City (“UMKC”) to disclose information in my education records, including any academic, performance,

financial, disciplinary, and personal information, to the following individuals or entities pursuant to the

Family Education Rights and Privacy Act (“FERPA”):

Name: _______________________________

Relationship to Student: ___________________

Address: ______________________________________________________________________________

Name: _______________________________

Relationship to Student: ___________________

Address: ______________________________________________________________________________

Name: _______________________________

Relationship to Student: ___________________

Address: ______________________________________________________________________________

If additional space is needed, please list additional individuals and/or entities on a separate form.

This release and authorization allows for the ongoing exchange of education records and information

between UMKC and the individuals and/or entities listed above. I understand that I may revoke this

consent, in writing, at any time, but revocation will not affect disclosures previously made by UMKC prior

to the receipt of any revocation.

I agree to release UMKC and its past and present officers, employees, agents, and successors, to the

maximum extent permissible under law, from all claims and liabilities for damages, known or unknown,

that may result from compliance with this authorization and release.

BY SIGNING BELOW, I UNDERSTAND AND AGREE WITH THE CONTENTS OF THIS AUTHORIZATION AND

RELEASE. I FURTHER UNDERSTAND THAT THIS IS A LEGALLY VALID AND BINDING OBLIGATION TO

RELEASE CERTAIN PARTIES FROM ALL KNOWN AND UNKNOWN CLAIMS.

Student Signature: _________________________________________

Date:_______________

Printed Name: _____________________________________

Student ID No.: ____________________

………………………………………………………………………………………………………………………………………………………………….

REVOCATION OF AUTHORIZATION

I hereby revoke authorization for UMKC to disclose records and information to the individuals and/or

entities listed above.

Student Signature: _________________________________________

Date:_______________

Education Records Information Disclosure Form - Revocation Of Authorization