Disclose the records to

Indicate the names of persons or institution whom shall the educational records shall be shared with

I hereby allow the disclosure of my or my child's educational information to the person or entity specified above (except health records):

I maintain my right to review prior disclosure to another my or my child's educational information for the following:

The records indicated above shall be released for the following purpose

This Consent is effective for the following period unless otherwise revoked:

Date Effective From:

Date

Date Effective Until:

Date

By signing this form, I give my express consent for the release of the educational records and within or without the limitations specified above.

I declare that I am executing this consent voluntarily and not under any form of threat, duress or intimidation.

Should I later decide to withdraw my consent, I may do so in the form of writing and be sent to the same institution executing this consent.

Name of Signatory

Signature

Clear

Date Signed

Date

Ferpa Consent Form