Student Consent Form For Release Of Confidential Information printable pdf download

Student Consent Form For Release Of Confidential Information

Student Consent Form for Release of Confidential

Information

University of Wisconsin – Stout

University Housing

I, _______________________ authorize ______________________________ to

(Name of Student)

(Name of Staff Member)

release the following information

: (examples of things that you may want to exclude:

sexual orientation, specific conduct information, academic status, information resulting from a

sexual assault, etc.)

_________________________________________________________________

1. _______________________________

2. _______________________________

3. _______________________________

4. _______________________________

5. _______________________________

(Name(s) of People or Organizations)

By signing below, I acknowledge that I understand that my confidential

information is protected under federal regulations governing The Family

Educational Rights and Privacy Act (FERPA) and cannot be disclosed without my

written consent unless otherwise provided for in the regulations. I also

understand that I may revoke this consent at any time in writing.

_________________________________________________________________

(Student Signature)

(Date)

_________________________________

(Student Name Printed)

_________________________________________________________________

(Staff Signature)

(Date)

__________________________________

(Staff Name Printed)

Student Consent Form For Release Of Confidential Information