Ferpa Release Form printable pdf download

FERPA RELEASE FORM

ACCESS TO STUDENT EDUCATIONAL RECORDS

In compliance with the Family Education Rights and Privacy Act (FERPA), a Federal Law that

protects the privacy of student education records, it is Phoenix Seminary’s (PS) policy to withhold

certain educational records unless the student provides consent to disclose information to a

specified individual. The purpose of this form is to provide the written consent to PS as required

by FERPA. The law applies to all schools that receive funds under an applicable program of the

U.S. Department of Education. A student also has the right to revoke the release of this

information at any time.

I, ____________________________________________________________________, give permission for PS to

release/discuss the specified educational records and information: (Check all that apply)

___All Records

___Financial Aid Records

___Academic Records

___Admission Records

___Accounting Records

___Military/Active Duty Records

___Veterans Records

___Registration Records

___Other_______________________________________________________________________________________________________

_________________________________________________________________________________________________________________

RELEASE/DISCUSS TO:

Name:_____________________________________________________________Relationship:_____________________________

Address:_________________________________________________________City, State, Zip_____________________________

I understand that by signing this authorization, I am waiving my rights of nondisclosure of my

educational records under federal law only to the person(s) listed. This release does not permit

the disclosure of this information to any other person(s) without my written consent.

By completing the form I will provide access to my records for a period of one (1) year or until I

revoke the form.

Student Signature

Date

4222 East Thomas Road, Suite 400

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Phoenix, AZ 85018

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602.850.8000

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Ferpa Release Form