Letter of Recommendation/Verbal Reference Release
The Family Educational Rights and Privacy Act (FERPA) prohibits an educational institution from releasing confidential, non-directory information about a student without the student's consent. A student may waive this right for college officials when written letters of recommendation or verbal references are required.
Student:
Complete this release form to authorize a Rochester University employee access to your education record for the purpose of constructing a recommendation. This form is not a request to provide a recommendation, but permission to use the content of these records. Each employee should be individually contacted to provide a reference.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Birthday
*
Please provide the last 4 digits of your social security number or student ID
*
Type 0000 if providing Student ID below
I agree to conduct this transaction electronically.
*
Yes
No
I authorize the following Rochester University employee to write a letter of recommendation or provide a verbal reference on my behalf:
Employee Name
*
First Name
Last Name
I grant the employee named above consent to provide a letter of recommendation or verbal reference to the following recipient:
Recipient Name
*
First Name
Last Name
Recipient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Recipient Phone Number
-
Area Code
Phone Number
Recipient Email
example@example.com
I give my permission to include the following non-directory information in a letter of recommendation/verbal reference (check all that apply):
Any information on my Rochester University transcript including my grades, GPA and courses taken.
Any educational or other records to which the employee has access to make academic and/or employment evaluations and decisions (including but not limited to examinations, essays, teaching/clinical evaluations, etc.)
The purpose of the information to be released (select all that apply):
Admission to an educational institution or program
Seeking employment
Military/Officer Candidate School
Scholarship eligibility
I understand that (1) I have the right not to consent to the release of my education records for this letter of recommendation; (2) I have the right to receive a copy of this letter upon request unless I waive that right; (3) and that this consent shall remain in effect until revoked by me, in writing, and delivered to Rochester University to the recipient provided for above, but that any such revocation shall not affect disclosures previously made by Rochester University prior to the receipt of any such written revocation.
*
I waive my right to review a copy of this letter of recommendation or to know the content of any verbal reference.
I do NOT waive my right to review a copy of this letter of recommendation or to know the content of any verbal reference.
By checking the box below, I release from all claims and agree to indemnify and hold harmless the individual providing this evaluation, Rochester University, its Board of Trustees, agents, officers, and employees, for any and all direct, indirect, special or consequential damages, or costs, legal and otherwise, for any statements made, consequences realized, or third party actions resulting from such recommendation, written or oral.
*
Agree
Disagree
Submit
Should be Empty: