Consent To Release Student Information - University Of Hartford printable pdf download

Consent to Release Student Information

The Family Educational Rights and Privacy Act of 1974 (FERPA) and the University of Hartford protect the privacy of

student educational records and generally limit access to the information contained in those records by third parties.

Please visit for responses to frequently asked questions regarding this Act.

You may choose to grant the University of Hartford permission to disclose educational records to certain individuals in

accordance with FERPA and University policy. Please complete this form and return it to the Student Administrative Services

Center (SASC) CC220, 200 Bloomfield Avenue, West Hartford, CT 06117, or your College Dean's Office, Residential Life Office, or

other student services offices as indicated below. The form will be kept on file in the Registrar's office.

Note: This form does not give permission to release any information with regard to health, counseling, disability, or public

safety records. PLEASE READ THE INFORMATION REGARDING FERPA ON THE BACK OF THIS FORM.

Student's Name: _____________________________________

University ID #: ____________________

I have indicated below the individual(s) or agency to whom the University may release information from my educational

records:

The individual(s) named below may have access to the following information: (Check all that apply)

First Individual/Agency

Second Individual/Agency

Full Name

Relationship to Student

Street

City / State / Zip Code

Telephone Number

Academic Information

Billing/Payment Information

Financial Aid Information

Residential Life Information

Student Conduct Information - *current

Student Conduct Information - all

Include all of the above

Remove all access

* current refers to either the year in which you are currently enrolled, or if completed after the spring term it refers to the next academic year.

I understand that I can revoke this release at any time by notifying SASC in writing (please note, it takes 24 hours to process the

request). Your request will automatically expire upon graduation or withdrawal from the University of Hartford. By signing this form I

acknowledge that I have read the information on the back of this form.

Student's Signature

Date

Please attach additional forms if you are giving permission

Print Name

to release information to more than two individuals/agencies.

Consent To Release Student Information - University Of Hartford