IUPUI Release of Student Information Consent Form
The Family Educational Rights and Privacy Act of 1974 (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. If you wish to authorize a specific individual or school/unit at
IUPUI to release information to specific individual(s), the following
form may be used.
Before completing and submitting the form, contact the
IUPUI
office/school to whom you wish to submit this consent form to assure
that they are able to comply with your request. Some schools do not have
a process in place to maintain such consent forms.
Instructions: Student should complete the form below and
return it to the appropriate school or office.
Please DO NOT forward this form to the
Office of the Registrar. While the Office of the Registrar
enforces FERPA regulations, the Office of the Registrar does
not maintain any signed student consents. Any such
arrangements must be made between the student and their
academic unit
|
School/Unit to Whom this Consent is being
Submitted ____________________________________ |
|
Name of School/Unit Contact ________________________________________________________ |
|
Address _________________________________________________________________________ |
Student
Disclosure and Release of Information
| I understand that any and all personally identifiable
information is protected under FERPA. I further understand
that I may waive that protection and give access to my
records for individuals of my choice. I agree to waive my rights under FERPA and allow the
individual(s) named below access to my financial and
academic records available at IUPUI. |
| NAME (First, Middle Initial, Last Name) Please
Print |
Relationship to Student |
| ________________________________________________ |
_______________________ |
| ________________________________________________ |
_______________________ |
| ________________________________________________ |
_______________________ |
I acknowledge that this release is valid until I have
completed my current degree program or until I revoke this
release in writing by notifying the IUPUI office
listed on this form. By signing this
release, I authorize IUPUI to release any and all financial
and academic information to the person(s) listed above.
|
| ________________________________________________ |
_______________________ |
| Student Signature |
University ID Number |
| ________________________________________________ |
_______________________ |
| Student Name - Please Print |
Date |
|
|
