Family Education Rights And Privacy Act (Ferpa) Release Form printable pdf download

FAIRMONT STATE UNIVERSITY

PIERPONT COMMUNITY & TECHNICAL COLLEGE

FAMILY EDUCATION RIGHTS AND PRIVACY ACT (FERPA) RELEASE

The Family Education Rights and Privacy Act (FERPA) is a federal law that protects the privacy of student education records, both

financial and academic. For the student’s protection, FERPA limits release of student record information without the student’s

explicit written consent; however it also gives the student’s parent(s)/guardian(s) the right to review those records if the

parent(s)/guardian(s) claim the student as a dependent on their Federal Income Tax Refund.

Instructions: Students complete part A OR parent(s)/guardian(s) complete part B. Return the completed form to:

FSU and Pierpont Enrollment Services, 1201 Locust Avenue, Fairmont, WV, 26554.

Part A -

TO BE COMPLETED BY THE STUDENT

If you want to authorize FSU and Pierpont to disclose information to the below named person(s), please complete Part A, sign, date,

and return this form to the institution as described in the instructions above.

Student Disclosure and Release of Information

I understand that any and all personally identifiable information concerning my financial and academic records is protected under

FERPA. I further understand that I may waive that protection and give access of my records to individuals of my choice. This release allows the

below named individuals to access information only from records maintained by the following Enrollment Services Offices: Office of Student

Accounts, the Office of the Registrar, and the Office of Financial Aid & Scholarships.

I agree to waive my rights under FERPA and allow the below-named person(s) to receive access to my financial and academic records.

NAME (First, Middle Initial, & Last) Please Print

RELATIONSHIP TO STUDENT

___________________________________________

______________________________________________

___________________________________________

______________________________________________

___________________________________________

______________________________________________

I acknowledge that this release is valid as long as I am a student at FSU or Pierpont. By signing this release, I authorize FSU and Pierpont to

release any and all financial and academic information to the person(s) listed above. I understand that I can revoke this release at any time by

notifying FSU and Pierpont in writing.

_______________________________________

_________________________

_____________________

Student Signature

Student F# (or Banner ID #)

Date

_______________________________________

Student Full Name (please print)

Part B –

(

)

TO BE COMPLETED BY THE PARENT

GUARDIAN

ONLY IF THE STUDENT DOES NOT COMPLETE PART A

In lieu of a student’s signed release, complete Part B of this form and attach a signed copy of your parent(s)/guardian(s) 2006

Federal Income Tax Return to certify that the student is your dependent according to Section 152 of the Internal Revenue Code. Part B is valid for

_______________________________________

Student Name – Please Print

only the current academic year. Since IRS dependency can change annually, you must submit copies of your Federal Income Tax Return each year

along with this form to continue access to your student’s records.

In order to gain access to my son/daughter’s financial and/or academic records, I certify that I am the parent(s)/guardian(s) of

(please print)_______________________________ with Student F# ___________________ and that he/she is dependent

according to Section 152 of the Internal Revenue Code.

_________________________________________

_________________________________________________

Parent/Guardian Name – Please Print

Parent/Guardian Signature

____________________________

Parent/Guardian Address: _________________________________________________

Date

_________________________________________________

Note to Parents/Guardian: If your child is not a dependent as defined by IRS standards, we will only be able to release information about his/her

financial and academic records if he/she completes Part A of this form. In the case of divorce or separation where only one parent claims the child

as a dependent, Fairmont State grants equal access to financial and academic records to the other parent if the information is completed in Part B.

Exceptions to this rule include a court order or legally binding documents stating otherwise.

Family Education Rights And Privacy Act (Ferpa) Release Form

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