FERPA 2020-2021

FERPA awards to students certain rights of access to educational records and imposes upon the university obligations concerning the release and disclosure of those records to third parties.

Therefore, each Belmont student will need to provide written consent on this form to release any informational, educational, or financial records to any party outside of his or herself. This form will need to be completed by the student.

The individuals specifically listed on this form will be granted access to share or discuss matters related to a student's account. If an individual is not listed on this form, (i.e. a parent), then the university cannot release any student information to that individual. However, this FERPA form also serves to notify the university of a student's dependent or independent familial status. The Buckley Amendment regulations allow the university to disclose information from an educational record to parent(s) or guardian(s) if a student is considered a dependent for federal income tax purposes.

Please email ferpa@belmont.edu if you have questions about this submission. Students can re-submit this information at any time and the information on the most recent submission will be honored.

Student Name*

First NameLast Name

Belmont ID Number*

This number is B00 followed by six unique digits

Belmont ID Number - retype for confirmation*

This number is B00 followed by six unique digits

Belmont ID Number fields must match before you can SUBMIT this form

Belmont E-mail Address*

Confirmation EmailTypically: first.last@bruins.belmont.edu (please verify before submitting)

Student Cell Phone Number*

Area CodePhone Number

Student Date of Birth*

Enter this field as MM/DD/YYYY

Individuals to Whom the Student is Granting FERPA Clearance

Provide the first and last name of each individual, (i.e. parent, guardian, etc.) and his or her affiliation to the student. For example: (Jane Doe-Mother)

Address for First Individual Named Above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Address for Second Individual Named Above: IF DIFFERENT

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Choose ONE of the Following Options:*

I am a DEPENDENT of my parents and I consent to the release of any educational or financial information to my parents whose names are listed above.The Buckley Amendment regulations allow the university to disclose information from an educational record to parent(s) or guardian(s) if a student is considered a dependent for federal income tax purposes.I am NOT a dependent of my parents, but I CONSENT to the release of my educational or financial information to my parent(s) or other/third-party individual(s) as listed above.I am NOT a dependent of my parents and I DO NOT CONSENT to the release of any educational or financial information to anyone other than myself. (If this choice is elected, only the Student Name and Belmont ID fields above should be completed.

Third Party FERPA Clearance: IF APPLICABLE

If an individual is not a family member, (i.e. legal representation, friend, etc.) list by first and last name here and include his or her affiliation to the student. For example: (John Doe-Business Associate)

NOTE: Although written consent may be granted, Belmont University has the right to use discretion when releasing records to third parties for the the protection of the students' record. A student, as the legal entity may be contacted by a Belmont official about releasing their information to a third party as a result of reasonable cause.

IF APPLICABLE, I consent to the release of any educational or financial records to the third party designee listed above:*

Additional Notes to the Office of the Registrar: IF APPLICABLE

ELECTRONIC SIGNATURE: Entering your name in this field will serve as your official signature of acknowledgement and approval. *

First NameLast Name

Please verify that you are human*