FERPA Consent Form

Alumni & Former Student FERPA Form

To be completed by alumni or former student.
Student's Name *

First Name Middle Name Last Name Suffix
Did you attend Stonehill under a different name? If so, please provide the name here.
Stonehill ID Number (if remembered)
Birth Date *

Month Day Year
Class Year *
E-mail *
Student's Phone Number *

Area Code Phone Number
Grant Permission

I voluntarily give Stonehill College faculty and staff my permission to discuss with the following person(s) (if any) information about me that I have checked off:
Name 1:

First Name Last Name
Relationship to Student:
The following information may be shared: (check all that apply)

AP - Academic Progress/Performance FA - Financial Aid File SA - Student Account/Billing
Add an additional person
Name 2:

First Name Last Name
Relationship to Student:
The following information may be shared: (check all that apply)

AP - Academic Progress/Performance FA - Financial Aid File SA - Student Account/Billing
Add an additional person
Name 3:

First Name Last Name
Relationship to Student:
The following information may be shared: (check all that apply)

AP - Academic Progress/Performance FA - Financial Aid File SA - Student Account/Billing
Decline Permission

Sometimes students are listed as a dependent on a parent or guardians' tax return. By law, Stonehill College faculty and staff may discuss academic progress/performance, financial aid, or student account/billing issues with that parent or guardian even if they are not listed above because they claim you as a dependent on their tax return, unless you decline to give us that permission below.
Do you give Stonehill Faculty and Staff permission to discuss academic/financial/billing issues with a parent or guardian not listed above, EVEN if you're claimed as a dependent on that person's tax return?

I Decline Permission I Grant Permission
I verify that I am the student signing this form and I understand under the Family Educational Rights and Privacy Act of 1974 (FERPA), that I may rescind or modify any of the permissions granted by providing a written request or updated FERPA Consent Form to the Registrar's Office of Stonehill College.
Who at the College should be notified that you are submitting this FERPA form? *
Student's Signature *

Click and hold with your mouse or finger to sign. Clear
Date *

Month Day Year
Any questions or concerns should be addressed to:

Stonehill College Registrar's Office
Duffy 112
320 Washington St., Easton, MA 02357
508-565-1315, registrar@stonehill.edu
http://www.stonehill.edu/offices-services/registrar/
Should be Empty:

Alumni & Former Student FERPA Form

Grant Permission

Decline Permission