Fillable 013117-FERPA-Consent-Form Policy on Staff Outside Employment and Additional University Services

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013117-FERPA-Consent-Form Policy on Staff Outside Employment and Additional University Services

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Consent to Disclose Education Records
The Family Educational Rights and Privacy Act of 1974 (FERPA) was designed to protect
the privacy of a student’s education records and to afford students certain rights pertaining to their
education records. The University of Dayton complies with FERPA and explains its procedures in
the University of Dayton Policy on Disclosure of Education Records. In accordance with
FERPA and its policy, the University of Dayton will disclose information from education records
with the student’s written consent.
By signing this document below, I consent for the appropriate record custodian to release
information from my education records to the following parties, as designated below:*
Parent(s)
Name(s)
Professor(s) or
All Professors Name(s)
UD Administrator(s)
Name(s) / Titles
Transferring Institution(s)
Name(s) of Institution(s) / Individuals’ Names
Other
Name(s) / Indicate Relationship (e.g., spouse, sibling, friend)
Types of Information
Grades/GPA Schedule Class Attendance
Billing statements, past due amounts, collection activity
Financial Aid awards, disbursements, eligibility
Disciplinary records
Records maintained by the Office of the Registrar
Student employment records
Records maintained by Center for International Programs
Other (explain)*
This authorization can be revoked by me at any time with written notification to the Registrar’s
Office.
Student Signature Date
Printed Name Student ID Number
* Consistent with FERPA, the University generally does disclose certain records without a student’s consent in a number of specified
circumstances. For more information, please consult Section A(III)(a) of the
University’s Policy on Disclosure of Education
Records
. Using this form to release records that are not technically education records does not transform those records into
education records. This “other” box should not be used to seek access to treatment or disability records.
Note: The form itself can be completed and submitted by logging into your student account through Porches OR should be delivered
by the student to Flyer Student Services located in Room 108 in St. Mary’s Hall; sent as a .pdf from the student’s UD email address
to registrar@udayton.edu; or sent by a Custodian/Gatekeeper through campus mail to Campus +1601.
Do not send form by facsimile.
BS-ID
FERPA
071218_FERPA_Consent_Form
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013117-FERPA-Consent-Form Policy on Staff Outside Employment and Additional University Services

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Completed 24 February 2020

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