Ferpa Release Form printable pdf download

FERPA RELEASE FORM

The Family Educational Rights and Privacy Act (FERPA) is a federal law that gives students various rights with respect to their educational records.

Under FERPA you have the right to inspect and review your educational records, the right to request amendment of records you believe are

inaccurate or misleading, and the right to prevent disclosure of information from your educational records without your prior consent, subject to some

specific exceptions. If you wish to authorize the release of records held by any of the departments listed below, please complete this form and

return to the address listed for your specific campus. Notaries are available on each campus at the Office of the Registrar.

I, ______________________________________, hereby authorize Rutgers University to disclose the following records upon request:

(Student’s Name)

Academic Transcript

Financial Aid Record(s)

Judicial Affairs File(s) (college or University)

Deans of Students Office File(s)

Student Accounts Information

Payment of Term Bill

Refunds

Financial aid applied to your account

Account Balance Information

Other: ________________________________________________________________

Residence Life File(s)

Other- Excluding Student Health (Description of Department): _________________________________________________

OR:

All of the above records

to ___________________________________________ at__________________________________________________________

To whom records are to be released)

(Address)

These records will be used for the purpose of: ____________________________________________________________________

(i.e., parental notification, letters of recommendation, employment inquiries, etc.)

This release shall be effective until ______________________ unless revoked in writing by me.

(Date)

_____________________________________________/________________________________/_______________________

(Signature)

(Student ID#)

(Date)

NOTARY PUBLIC:

State of ___________________________, County of ___________________________

The foregoing release form was acknowledged before me by ___________________________________________,

this ______________________________ day of _________________________, __________________.

Witness my hand and official seal: ________________________________________________________

My commission expires on: ______________________________________________________________

New Brunswick Campus

Camden Campus

Newark Campus

RBHS

Office of the Registrar

Administrative Services Building

Armitage Hall

249 University Avenue

65 Bergen Street

65 Davidson Rd, 200L

311 North 5

Street

Blumenthal Hall

Suite 1441

Piscataway, NJ 08854-8096

Camden, NJ 08102-1499

Newark, NJ07102-9286

Newark, NJ 07101

Phone:

848-445-2738

Phone:

856-225-6053

Phone:

973-353-5324

Phone: 973 972 5338

Fax:

732-445-5948

Fax:

856-225-6453

Fax:

973-353-5324

Fax:

973 972 5320

iuso@rci.rutgers.edu

Dean’s Office

Financial Aid

Student Accounts

Residence Life

Judicial Affairs

Other: _________________

FERPA 091715

Ferpa Release Form

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