A
UTHORIZATION
FOR RELEASE OF STUDENT
R
ECORDS
In accordance with the Family Educational Rights and Privacy Act (FERPA), Yuba Community College District (YCCD) may only release student
records directly to the student, unless prior written authorization is given by the student. By filling out this form you give permission for others
to view and have access to your student records. Also, this form is used to opt-out of your directory information being released to anyone.
STUDENT INFORMATION:
Please print
Student ID or last 4 digits of SSN
CHECK TO INDICATE WHICH RECORDS TO BE RELEASED:
All Academic Records (records include: transcripts, admissions and registration information, class schedules, grades, assessment test scores,
academic progress status, residency information, and any other documentation contained in the academic records)
All Student Account Records (records include: amounts due for tuition and fees, sources of payment for tuition and fees, refund information, records hold
information as it relates to parking tickets, library fines, financial aid repayments and any other information contained in student account records)
All Financial Aid Records (records include: status of file, award and disbursement of funds information, satisfactory academic progress status, income
information, and any other information contained in the financial aid application or file)
Other (Please specify)
THE FOLLOWING INDIVIDUALS ARE AUTHORIZED TO ACCESS THE INFORMATION SPECIFIED ABOVE:
Please print
Other (Name and Relationship):
Agency (Name, Address and Phone):
OPT OUT:
Do not disclose any directory information (Directory Information: Name, address, telephone, email address, photograph, dates of attendance,
student ID number and
gender)
STUDENT SIGNATURE:
I understand that although I am not required to release this information, I am giving my consen
t to Woodland Community College to disclose
these records. This authorization will expire at the end of the academic term unless a written request is submitted to authorize disclosure.
STUDENT SIGNATURE
___ ___ ___ ___ ___ ___
DATE
*****************************************************************************************************************************************************
FOR DISTRICT A & R USE ONLY
Government issued photo ID verified by:
FERPA notification assigned by: Release expires: ___ ___ / ___ ___ / ___ ___
Revised 11/15/2017
