2020-2021
Student Information
Release (FERPA) Form
Completed form may be submitted in-person, via mail, or fax to the following offices. Do Not E-mail Form
Admissions & Records Office
Mail: 570 Golden Eagle Ave, Quincy, CA 95971
Mail: 570 Golden Eagle Ave, Quincy, CA 95971
Subject to certain exceptions (known as directory information) set forth in the Federal Family Education Rights and Privacy Act (FERPA) of 1974, Feather
River College
will not provide personally identifiable student information to third parties without the student’s signed, written permission. This
information includes, but is not limited to:
registration, student financial records, assessments, financial aid, and other student records.
Note: this student information release form remains in effect for one academic year (July 1, 2020 – June 30, 2021)
You, the student, may grant Feather River College permission to release authorized information to a third party by submitting this completed form. Third
parties include,
but are not limited to: parents, spouses and third-party sponsors. A separate form must be submitted for
each person/agency
to which
you wish to grant access to your
information. Authorized information will be provided only upon request by, and proof of identity of, the third party.
Print Student Information
FRC ID Number:
__________________________
______________________________________________________________________________________________________________________________________
First M.I. Last
______________________________________________________________________________________________________________________________________
Current Mailing Address City State Zip Current Phone Number
Print Third Party Designee: PERSON (parent, relative, spouse, etc.)
_____________________________________________________________________________________________________________________________________
Name Relationship to Student
_____________________________________________________________________________________________________________________________________
Address (City, State, Zip) Birthdate Last 4 Digits of SSN
P
rint Third Party Designee: AGENCY (scholarship donor, employer, etc.)
______________________________________________________________________________________________________________________________________
Name Agency/Organization
______________________________________________________________________________________________________________________________________
Address (City, State, Zip) Phone Number
Information Types Allowed (Check one or more of the boxes below to grant authorization):
☐
Registration, academic performance/standing, class schedule, transcripts and/or enrollment information, degree, grade point average, housing (
Registrar
)
☐
Financial aid awards, application data, disbursements, eligibility and/or financial aid satisfactory academic progress (
Financial Aid
)
☐
Finance-related records, including billing statements, charges, credits, payments and past-due amounts (
Registrar
)
☐
All Veterans Education Benefits Information (
Financial Aid
)
☐
Housing & Homeless Services/Foster, Homeless & Transitional Youth Services (
Financial Aid
)
Incomplete, incorrect, unsigned or undated forms will not be accepted and will be returned to the student.
By submitting this form, you
are not
giving the third party authorization to speak, act, or sign any documents on your behalf. If you are
contacted by phone by any college
department, the college reserves the right to speak only to you and no one else.
Certification:
By signing below, I consent to the release of the personal student information specified above to the individual or agency listed.
This worksheet must be signed and dated to be valid. Electronic and/or digital signatures are not valid.
Student’s Signature: _______________________________________________________ Date: _____________________
☐ Comment in SPACMNT about info released
☐
Add ‘RELEAS’ in RRAAREQ | Status = S
