John Melvin University FERPA Release

John Melvin University FERPA Release

Consent to Release Form
Student Name*

First NameLast Name
Student Email*
example@example.com
Student Date*

MonthDayYear
Date
Subject: Authorization for the Release of Confidential Financial and/or Academic Information

Pursuant to the Family Education Rights and Privacy Act of 1974 (FERPA), as amended, and the John Melvin University Policy Governing the Release of Student Information, I authorize, by my signature, the release of all financial data pertaining to my enrollment to the following individual:
I am giving permission to release the following information to the person(s) listed below: (choose all that apply)*

AcademicFinancialMedical (medical records, medical information, health-related topics, mental illness issues, emotional and processing behaviors, etc). This includes any observed behaviors or language that is concerning to other students, faculty, staff, etc.
List ALL individuals that John Melvin University/John Melvin Christian College are allowed to speak to regarding the above mentioned topics. If more than three individuals are required, please submit this form and complete another FERPA JotForm for the remaining individuals you would like to grant access to your records.
1. Parent/Guardian/Individual Name*

First NameLast Name
1. Parent/Guardian/Individual Email*
example@example.com
1. Parent/Guardian/Individual Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Parent/Guardian/Individual Name

First NameLast Name
2. Parent/Guardian/Individual Email
example@example.com
2. Parent/Guardian/Individual Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Parent/Guardian/Individual Name

First NameLast Name
3. Parent/Guardian/Individual Email
example@example.com
3. Parent/Guardian/Individual Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's Signature*

Clear
Date*

MonthDayYear
Date
Upload an image of your Driver's License or Social Security Card for Identification Purposes*

Cancelof
Recipient's Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: