Information Release Request

Information Release Request
Information contained in a student's academic file is protected by FERPA (Family Education Rights & Privacy Act) and can only be released by a signed written request from the student. The student should fill out this form and fill in all the fields. A signature by the student is required before any information can be released from their file.
Student's Full Name*

FirstMiddle NameLast
Maiden name if applicable
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Last Four Digits of SSN:*
example: xxx-xx-1234
Information from file that is requested:*
Individual/Organization student is giving permission to obtain this information:*
By signing below, I certify that I am the student submitting this request. I recognize that §99.30 of the FERPA regulations requires that a student provide a signed, dated, written consent before an institution discloses information from the student's education record. Forgery of this document is a Federal criminal offense that is punishable as a felony in all 50 states.*

I accept
Signature*

Clear
Should be Empty: