Ferpa Consent For Release Of Student Information Form
ADVERTISEMENT
1Registrar’s Office, Virginia International University
11200 Waples Mill Road Suite 360
Consent for Release of
Fairfax, VA 22030
Phone: 703-591-7042
Fax: 703-591-7048
Student Information form
Email: registrar@viu.edu
I,
Student ID:
Birth Date:
First
Middle
Last
hereby authorize Virginia International University to release the following information about me:
All academic records ( admission, attendance, registration/enrollment, grades, GPA, academic standing, graduation/degree)
All accounting information.
OR only these specific items (check individual items):
ACADEMIC:
Admission
Attendance
Registration/Enrollment
Academic Standing
Grades
GPA
Graduation/Degree
Other
To the following individual (s) upon their request:
1.
(Printed Name)
(Relationship to Student)
Address
Email
2.
(Printed Name)
(Relationship to Student)
Address
Email
Duration of Release (please check one)
Use until I complete a new release
One time use: This release can only be used once
Purpose of Release
Family Communication
Admission to an Educational Institution
Employment
Other (please specify):
I understand that this information is considered a student education record. Further, I understand that by signing this release, I am waiving my
right to keep this information confidential under the Family Educational Rights and Privacy Act (FERPA). I certify that my consent for disclosure of
this information is entirely voluntary. I understand this consent for disclosure of information can be revoked by me in writing at any time, but will
not affect the information release under my previous consent. If I wish to make any changes to my consent for release, I understand I will need to
complete and file a new form. The authorization on this form will supersede all prior authorizations for release of my information.
I wish to revoke all consent for release of information.
Student’s Signature:
Date:
Office Use Only
Date Received : _________________________By: _____________ Date Processed:______________ By: ________________
Rev:06/2014
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal