Ferpa Release Form

Name of Institution releasing the records

Student Name

PrefixFirst NameMiddle NameLast NameSuffix

Student Number

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Effective for this academic year:

Example: 2019-2020

The Family Educational Rights and Privacy Act (FERPA) provides that {nameOf10} is allowed to disclose student records to parents if at least one of the parents claim the student as their dependent.

In case that that I am not a named dependent of my parents, I likewise give consent to the release of any school records related to me.

Please select the appropriate option:

Yes, I certify that I am a dependent to my parents for federal income tax purposesNo. I certify that my parents do not claim me as a dependent for federal income tax purposes.I am not registered as dependent to the named recipient(s) indicated but I am giving my full consent to the disclosure of my educational records to themI am not registered as dependent to the named recipient(s) indicated but I am giving my partial consent to the disclosure of my educational records to them

Records to be Released for Partial consent

Ferpa Release Form

Recipient Information and Confirmation