Ferpa Authorization To Release Information From Student Education Records Form - Spokane Community College

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FERPA AUTHORIZATION TO RELEASE INFORMATION
FROM STUDENT EDUCATION RECORDS
Reset Form
The Family Educational Rights and Privacy Act (FERPA) is designed to protect the privacy of a student’s educational
records. These records may include academic, financial aid, scholarship, athletics, veterans, and billing/account
information. Records will not be released without prior written consent from the student. By signing this form, the
student authorizes college officials to release and/or disclose specific educational records requested to the designated
recipient.
Please note that certain information, defined as directory information, can be released without the prior consent of the
student.
REQUESTED BY (STUDENT):
Student Last Name
First
M.I.
Address
City
State
Zip
E-mail
Phone (
)
-
SSN
SID
Optional
Required
Birthdate (mm/dd/yyyy)
/
/
I am a
Current Student
Former student
at the location of
Spokane Community College
Spokane Falls Community College
Institute of Extended Learning
I hereby authorize the release of the information specified below for the period of time indicated, unless
revoked by me in writing to the appropriate CCS Registrar’s Office.
Information to be Released
Duration of this Authorization
All education records (GPA, grades, enrollment, etc.)
Until Date
/
/
Dates of Attendance
Until I graduate or am no longer enrolled/leave
CCS
Financial Aid, Grants, Scholarships
Billing Information
Other, please specify
Purpose of this authorization – Please check all that apply
Education Records
Financial Aid (*Code word
)
Insurance/Benefits reporting
Student Financial Account (*Code word
)
Athletics
Veterans
Billing
Other, please specify
*Must add and give to those that you are requesting to have access to your financial information.
Release to (Recipient):
Organization
Phone Number (
)
-
Name
Relationship to student
Address
City, State, Zip
E-mail
Fax Number (
)
-
CCS 40-200 (Rev. 06/12)
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