Authorization And Request For Release Of Records And Information printable pdf download

Authorization And Request For Release Of Records And Information

Office of the Registrar, Student One Stop

Meshel Hall

Phone: 330-941-6000

Fax: 330-941-3154

One University Plaza, Youngstown, OH 44555

Email: onestop@ysu.edu

AUTHORIZATION AND REQUEST FOR RELEASE OF RECORDS AND INFORMATION

This authorization shall be considered as a waiver of any and all of my rights and/or privileges as provided

under the Family Education Rights and Privacy Act of 1974 (FERPA) and/or Gramm-Leach-Bliley Act of 1999

(GLBA).

I, _____________________________________________, hereby authorize the disclosure, furnishing and release

of the following information relating to or concerning me to the person(s) listed below without my further consent:

Print Name: _____________________________

Relationship: ___________________________________

Print Name: ______________________________

Relationship: ___________________________________

___ Academic Grades/Records

___ Academic Advising

___ Billing Records

___ Financial Aid Records

___ Housing Information/Action

___ Student Conduct

___ Other Information (please specify): ________________________________________________________

NOTE TO STUDENT: To finalize the processing of your authorization, you must deliver this form IN PERSON to the

Office of the Registrar, Student One Stop along with photo identification. This form will not be accepted without

proof of identification in order to ensure the protection of your information.

Student Signature: __________________________________________________________________________

Student ID#:________________________________

Date: ______________________________

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If, in the future, you wish to rescind your request to release records, you must return to the office where you

submitted this form and sign below:

I hereby rescind my request to release information to the above named individual(s).

Student Signature: _____________________________________________

Date: ___________________

FOR OFFICE USE ONLY

[

] Student ID Verified

[

] Comments Placed in Banner

[

] Staff Initials

Rev. 2/10/15

Authorization And Request For Release Of Records And Information