FERPA Academic Record Release Form

FERPA Academic Record Release Form
The Family Educational Rights and Privacy Act of 1974 (FERPA) prohibits the release of certain information without the expressed consent of the student.

Please complete this form, indicating your choice regarding the release of your academic records.

This statement shall be in effect for all terms of enrollment, unless a subsequent form is filed.

Questions? Please email registrar@umsv.edu.
Student Name:*

First NameLast Name
Student ID Number:*
Please enter the names of your parents/guardians/spouse/other, separated by a comma:*
I give permission for my academic records to be released to my parents/guardians/spouse/other as designated above, upon their request.*

YesNo
Please be advised that the University of Mount Saint Vincent reserves the right to
contact the parents/guardians of dependent students regarding disciplinary violations of any law, rule, or policy governing the use or possession of alcohol or a controlled substance, if the student is under the age of 21. The University also reserves the right to disclose the final results of any disciplinary proceeding against a student in connection with an alleged crime of violence or non-forcible sex offense to anyone, including the general public, if the University determines that the student committed a violation of its rules or policies with respect to such crime or offense.
Student Signature:*

Clear
Toady's Date:*

MonthDayYear
Should be Empty: