Student Reference Request, Ferpa Release, And Release Of Liability printable pdf download

Student Reference Request, FERPA

Release, and Release of Liability

OFFICE OF THE REGISTRAR

Instructions

Students requesting a letter of reference from a faculty or staff member may be asked to provide a release allowing the

faculty or staff member to access the student’s education record. Complete this form and print a copy for the person

completing the reference.

Student ID number: _______________

Student name: __________________________________________________

I request: _______________________________________________________________ to serve as a reference for me.

The purpose(s) of the reference are: (check all applicable spaces)

______ Application for employment

______ All forms of scholarship or honorary award

______ Admission to another education institution

The reference may be given in the following form(s): (check one or both spaces)

______ Written

______ Oral

I authorize the above named person to provide an evaluation of any aspect of my academic performance, whether based

on personal observation or on my education records at UMKC, and to release information from my education records,

including my grades, GPA, class rank, any information pertaining to my education at other institutions I have previously

attended, and any other personally identifiable information. I authorize release of this information and reference or

evaluation to: (check all applicable spaces)

______ All prospective employers OR

______ Specific employers (list name and address on reverse side)

______ All educational institutions to which I seek admission OR

______ Specific educational institutions (list name and address on reverse side)

______ All organizations considering me for an award or scholarship OR

______ Specific organizations (list name and address on reverse side)

I understand that under the Family Educational and Privacy Rights Act: (1) I have the right not to consent to the release of

my education records; (2) I have the right to receive a copy of any written reference upon request; and (3) I may, but am

not required to, waive my right of access to confidential references given for any of the purposes listed above.

______ I waive my right of access to references given by the above named person.

______ I do not waive my right of access to references given by the above-named person.

This consent shall remain in effect until revoked by me, in writing, and delivered to the above named person, but any such

revocation shall not affect disclosures made prior to the person’s receipt of my written revocation.

I release UMKC, its employees and the person(s) providing the above described reference or evaluation from all claims

and liability for damages that may result from their compliance with this request.

Student signature: _______________________________________________

Date: ___________________________

Revised: April 1, 2008 ndsw

Student Reference Request, Ferpa Release, And Release Of Liability