Consent to Release Student Education Record Information
The Family Educational Rights and Privacy Act (FERPA) of 1974, as amended, seeks to guarantee both a student’s right of access to records and the confidentiality of student information. In accordance with federal law and College policy, we generally will not share student academic information (apart from directory information) with third parties, including parents or spouses, without student consent. This form allows students to grant parents, guardians, spouse, and/or others access to all academic records, including grades and financial information associated with those records. This form does not pertain to medical records or inquiries. All permissions granted will stay in effect until revoked by the student.
Name:
*
First Name
Last Name
Student ID number:
*
ex: 111-11-1111
Southwestern Email:
example@sckans.edu
Parent/Guardian 1
Name
*
First Name
Last Name
Relationship to Student
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Parent/Guardian 2 (optional)
Name
First Name
Last Name
Relationship to Student
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Identity Question/Answer for designated person(s)
Identity questions will be used as part of the verification process
In what city or town was your mother born?
*
What was the name of the street on which you grew up?
*
What was the name of your first pet?
*
Student Consent
I give my permission for the above person(s) to have access to my academic records. Note: If directory information has been restricted (see next page for definition) then no information will be released even to the parties designated above.
Student Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: