Summer at IUPUI

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