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 listed below: (choose all that apply)*

AcademicFinancial
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Email*
example@example.com
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: