Student Consent Form For Release Of Education Records

Student Consent Form For Release Of Education Records - Ferpa

FERPA STUDENT CONSENT FORM FOR RELEASE OF EDUCATION RECORDS

__________________________

__________________

_______________

Name of Student

Student ID #

Date

The Federal Educational Rights and Privacy Act of 1974 (FERPA) affords certain rights

to students concerning the privacy of, and access to, their education records. Third

parties under FERPA cannot access your records without your written permission.

However, students may choose to complete this form to allow release of their education

records to specified third parties.

Even with this consent form, information cannot be given to a third party via the

telephone or e-mail. For additional information, visit the NSU FERPA information page

or the U.S. Department of Education’s website at

By completing, signing, and dating this consent form, I am giving faculty of the

Northwestern State University of Louisiana, Department of Social Work my permission

to release to representatives of potential field placement agencies, the following

information: A copy of my completed Field Placement application. This information is

to be used only in determination of placement in a Field Placement Agency.

I understand that (1) I have the right not to consent to the release of my education

records, (2) I have the right to inspect any written records released pursuant to this

consent, and (3) I have the right to revoke this consent at any time by completing the

section below.

_________________________________

_______________________

Student’s Signature

Date

**You must put your correct Student ID#**

Please sign and date below ONLY if you are revoking this consent.

I hereby REVOKE the right of NSU, Social Work Department representatives to provide

my field placement application to any community agencies. I understand that this

revocation cannot apply to actions taken prior to this revocation date.

_________________________________

_______________________

Student’s Signature

Date

Student Consent Form For Release Of Education Records - Ferpa