Ferpa Release Of Student Information Form
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1FERPA - Release of Student Information Form
Student’s Name
Macomb Student ID Number
Date of Birth
Street Address
City
State
Zip
Phone Number
I authorize Macomb Community College to grant access to my educational record to the individual
listed below. I understand that I must provide written notification to Macomb Community College,
Office of Enrollment Services if I no longer wish for access to be granted to this person. This form will
expire two years from the date of signature at which time, a new form would need to be completed.
Please Select the Type of Information to be Released (plus select all that you would like applied):
Enrollment Records – Admissions Application, Update Form, Grades, Access to Academic Record,
Attendance Records, Speaking with Academic Faculty/Administrator on Student Behalf
Financial Aid and Student Account Records –Financial Aid application documents (including FAFSA), status,
awards and related information. Student Account invoices, statements, payments, charges, credits, tax forms
(including 1098T) and related information.
Counseling, Academic Advising & Special Services Department
Dean of Students Success Office
Release of My Student Educational Record Will Be Granted To:
(Upon Verification of Person by Date of Birth and Last 4 Digits of SSN)
Full Name of Parent/Spouse/Other
Relationship to Student (check one):
□ Parent
□ Spouse
□ Other ___________
Date of Birth of Parent/Spouse/Other
Last 4 Digits of Parent/Spouse/Other SSN
Student’s Signature
Date
**This form MUST be completed by the student in person by providing a picture ID. Send to
FERPA@macomb.edu
for processing**
Academic Office
Signature of Academic Department
Sent to
FERPA@macomb.edu
Date
ES Office Use Only
Noted on PERC & Document Image to record
Staff initials
Date
REV 6.16.14
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Parent category: Legal