2017-2018 Consent to Release CNSRL
2017-2018 Academic Year
Consent to Release Information
The Family Educational Rights and Privacy Act (FERPA) of 1974 is designed to protect
the privacy of a student’s educational records. These
confidential records include
financial aid, scholarship, and student account information, and will not be released
without written consent from the student. By signing this form, the student authorizes
MSJC personnel to release confidential financial aid
information to a designated
person(s).
Person to Release Information To
Full Name: ___________________________
Relationship to Student: ___________________________
Driver’s License #: ___________________________
Date of Birth: ___________________________
I understand the person (s) listed on this form will have access via telephone, and in person, or by
mail to information that may include the following initial by me below:
This is to be completed at the Financial Aid Office or Veterans Resource Center
ITEMS TO BE DISCLOSED: APPLICANT’S INITIALS
Financial Aid Application Status
Satisfactory Academic Progress
Financial Aid Disbursement
Financial Aid Holds
Statement of Responsibility Status
Veteran Standards of Progress
________________________________ _________________
Student’s Signature Date
This document must be completed and turned in at the Financial Aid office with proper
identification by the student. Also, attached photocopy of ID of person to release
information to. Forms will not be accepted by anyone other than the student.
______________________________________________
For Office Use Only
Staff Initials: ___________ Date Entered: _________
Return to:
Financial Aid or Veterans Resource Center
Student’s Name:
(Please print clearly in blue/ black ink)
Last:___________________________________________________________
First: __________________________________________________________
Student ID Number: __________________________________________
Financial Aid and Veterans Services
click to sign
signature
click to edit
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