Family Educational Rights & Privacy Act (Ferpa) Waiver
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____ _____________________________ ______________________ _______ ____________
Receiving Staff Signature
Office
Date
__________________________________ _____________________________
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Processing Staff Signature
Office
Date
Family Educational Rights & Privacy Act (FERPA) Waiver
The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) is a Federal law that
protects the privacy of student education records. These records include grades, judicial sanctions, financial records
and other personal information.
Salem State University is committed to following federal law and protecting the privacy of students and will not
disclose any protected information from our student records. In addition, the university will refrain from sharing non-
directory information to any individual, including parents or guardians, without the written consent of the student. By
signing this waiver a student is authorizing the designated university office to share information with select
individuals and/or parties; however, the student will remain the primary contact person.
I, ____________________________________________________________, student ID# _______________
understand the Family Educational Rights and Privacy Act (FERPA) as it relates to information from my
educational records, and my right to keep such information confidential. I hereby consent to allow the
designated office(s) at Salem State University to disclose information from the following records:
On-Campus Housing
Student Life Office
Academic Records
Financial Aid
Student Accounts
All Student Records
Other – (Please specify): __________
I hereby authorize said disclosure to be made to the following person(s):
Entity #1
Entity #2
___________________________________________
___________________________________________
Individual
Individual
___________________________________________
___________________________________________
Street Address
Street Address
___________________________________________
___________________________________________
City, State, Zip
City, State, Zip
___________________________________________
___________________________________________
Phone
Phone
___________________________________________
___________________________________________
Relationship
Relationship
____________________________________
____________________________________
Security Word
Security Word
I have read this document in its entirety and I understand the content. I agree to allow the designated
university office(s) to share information with the identified individual(s) named above. I understand that in
order to rescind this waiver I must do so in writing at the Registrar’s Office. I also understand that this
waiver does not authorize the release of any counseling and health services treatment records as it is
outside the jurisdiction of FERPA.
Student Signature: ___________________________________________ Date: _________________
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