FERPA Information Release Form

FERPA Request for Records Release, Records Inspection & Directory Opt-Out

Last Name *

First Name

Middle Name

Last Name

Student Social Security Number/ID *

Release information to the third party that I list below*

Release information to the third party that I list below Cancel my authorization to release information to the third party that I list below

(Last Name, First Name, Middle Initial or Agency/Organization Name) *

First Name

Last Name

Relationship to Student *

Billing statements, charges, credits, payments, past due amounts, and/or collection activity

Address Line 1

Address Line 2

City

State

ZIP Code

Grades/GPA, demographic, registration, student ID number, and academic status progress, enrollment information

Financial Aid awards, application data, disbursements, eligibility, and/or financial aid satisfactory academic progress status

Other

Additional request

Withhold my Directory Information An inspection of my academic records.

Other:

Please select one or more options

If Other, Please Specify

Student CWID *

Month*

Signature (Full Name) *