Ferpa Information Disclosure Consent Form printable pdf download

Office of the Vice Provost for Enrollment Management

Family Educational Rights and Privacy Act (FERPA) Information Disclosure Consent

Student Name _____________________________________________ Person Number _____________________

The Family Educational Rights and Privacy Act (FERPA) is a Federal Law that protects the privacy of student education records.

Schools may disclose, without consent, “directory” information such as a student’s name, address, telephone number, date and

place of birth, honors and awards, and dates of attendance. If students do not wish for directory information to be released, UB’s

request for non-release of directory information

is available at:

Schools must have written permission from the student in order to release non-directory information (such as academic or

financial information) from a student’s record. However, FERPA allows schools to disclose records without consent to

certain

parties under certain

conditions. More information about

FERPA and UB

is available at:

By signing this document, I am giving or revoking consent that University at Buffalo officials may discuss the contents

of my academic record (including courses, grades, and degree progress) and/or financial record (including student

account information and financial aid) with the following parties. I understand that I may revoke consent at any time by

submitting a revised form. Additional individuals can be identified by submitting additional forms.

Note: Access to student account information can also be granted by adding an

Authorized Payer

in your HUB Student Center.

Individual to whom I am granting or revoking

Additional individual (if applicable) to whom I

access to my records:

am granting or revoking access to my records:

Name

Relationship to

Student

Phone

Academic

Grant Consent

Revoke Consent

Grant Consent

Revoke Consent

Records

Financial

Grant Consent

Revoke Consent

Grant Consent

Revoke Consent

Records

This form must be completed by the student in person with photo identification at the University at Buffalo in the presence of an

appropriate staff member. If the student is unable to do so, the form may be notarized by a Notary Public and submitted by fax,

email or mail to the office with which the student is directly interacting or the Office of the Registrar at 716-645-7762 (fax),

UBReg@buffalo.edu, 232 Capen Hall, Buffalo, NY 14260.

Student Signature_________________________________________________ Date_____________________

For use by Notary Public if returned by fax or mail: State of _________________ Country of ____________________

Before me, the undersigned notary public, this day, personally, appeared ___________________________ to me known, who

being duly sworn according to law, deposes the following:

____________________________________________

(Signature of Affiant)

Subscribed and sworn to before me this ______________ day of ____________________, 20_________.

Notary Public: ____________________________________ My Commission expires: _______________

For staff use only

Verified by: Staff Name: __________________________________________

Phone ___________________

Staff Signature: __________________________________________________

Have you entered the Service

Signature indicates that you have validated the student’s identity via their

Indicator in HUB?

UB Card or government issued ID.

Yes

Ferpa Information Disclosure Consent Form

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