Buiness Office Student Information Release Form

Business Office Student Information Release Form
The Family Education Rights and Privacy Act (FERPA) is a Federal law that protects the privacy of student education records. Under FERPA, a school may not generally disclose personally identifiable information from an eligible student"s education records to a third party (including parents) unless the eligible student has provided written consent. All students must complete this form even if you do not want to provide consent. More information on FERPA can be found at http://www.ed.gov
STUDENT INFO
First Name *
Last Name *
Date of Birth *

Month Day Year
Date
Do you wish to allow persons you specify access to your business office records? *

Yes No
List all persons you allow access to your information
Would you like the Business Office to send a copy of your monthly statement of your student account to someone? *

Yes No
I would like a copy of my monthly statements sent to the following email address. In submitting this form, I also understand that a copy will continue to be sent to this address the entire time I am a student at ABC until I notify the Business Office in writing to stop sending to this address.
Send to Name
Send to Email
example@example.com
Do you allow the Business Office to share only your account balance to any persons desiring to make a payment on your account? *

Yes No
AUTHORIZATION OF DISCLOSURE
I understand that this agreement to disclose my business office records will be in effect from the date signed through my entire period of enrollment at Appalachian Bible College. I further understand that I must notify the Business Office, in writing, if I choose to modify or revoke this agreement.
Signature (full name) *
Date *

Month Day Year
Date
Last 4 Digits of SSN
Should be Empty:

Business Office Student Information Release Form

STUDENT INFO

AUTHORIZATION OF DISCLOSURE