FERPA Form

STUDENT CONSENT TO RELEASE EDUCATION RECORDS
In accordance with federal legislation, the Family Education Rights and Privacy Act (FERPA), I understand that my educational records cannot be released, with the exception of Directory Information, without my writing permission.

The University of Pikeville is required to provide information to Immigration and Customs Enforcement (ICE)

Student Conduct Records: University officials will only release student conduct information upon receipt of a signed,dated,written consent of the student that must specify the timeframe along with the party to whom the disclosure may be made to the Student Services office.

Medical Records: The University of Pikeville does not consider medical records part of the students’ education record. Medical records made and maintained in the course of treatment and disclosed only to those individuals (physician, psychiatrist, psychologist, counselor, other recognized professional, or paraprofessionals) providing treatment. Otherwise, the student must specify if records of this nature may be disclosed and identify the part to whom the disclosure may be made by way of a signed, dated, and written consent to the Student Services Office.

I, therefore, consent to the following person(s) receiving information providing a password is provided with the request:
Name*
Password*
Relationship to Student*
Name
Password
Relationship to Student
Name
Password
Relationship to Student
Information to be released to individuals listed above (check all that apply):
Check all that apply:*

Academic Records (Registrar’s Office)(includes a copy of schedule, advisor assignment, verification of enrollment)Note: grades and transcripts are not includedFinancial Aid Records (Financial Aid)(includes FAFSA, loans, Federal Work Study, award letters, verifications, SAP –Student Financial Records (Business Office)(includes a printed account statement, account balance, specific charges on account, financial aidapplied, refund schedule, amount of aid anticipated to receive, payments made on the account, paymentamount and due dates, restrictions, questions on 1098T forms, and Perkins Loan Records)
I understand that (1) I am not required to consent to the release of my education records; (2) This authorization will remain active for the duration of my enrollment at UPIKE; (3) I have the right to inspect any written records released pursuant to this consent; and (4) I have the right to revoke this consent at any time by notifying the Registrar’s Office.
Student’s Name*
UPIKE ID*
Telephone*
(555)555-5555
Mailing Address
Signature of Student (Your signature and ID card may be verified when submitted)*

Clear
Date*

MonthDayYear
Return to: Registrar’s Office or email to registrar@upike.edu
Should be Empty:

STUDENT CONSENT TO RELEASE EDUCATION RECORDS

Information to be released to individuals listed above (check all that apply):