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FAMILY Educational Rights and Privacy Act (FERPA)
Authorization to Release Information to a Third Party
Student Name: ________________________________________________________________ NECC ID no.:
The Family Educational Rights and Privacy Act (FERPA) prohibits an institution of higher education from releasing most student record information to
any requesting third party, absent the student’s prior written consent. Failure of the College to comply with FERPA may result in a violation of federal
law and jeopardize the College’s federal funding. I authorize Northern Essex Community College to release my educational record information to:
Name of Individual: Relationship:
I authorize NECC to release the following information (check all that apply):
Student Accounts: Includes tuition and fee balance, nancial holds, mailing and billing address, payment plans, accounting statements, collections
information, and debt information.
Admissions: Includes the date of application, program selected, documents received, documents pending, date of admission, admissions status,
and condition of admission.
Registration: Includes current enrollment, date of enrollment activity, enrollment status, residency status, semesters attended, and mailing address
information.
Academic Records: Includes courses taken, grades received, GPA, academic progress, honors, transfer credit, and degrees earned.
Financial Aid: Includes all general nancial aid information.
CODE WORD: __________________________________ (The code word is used to validate your authorized individuals. Please provide your code word to
the authorized individuals listed above).
Emergency Contact Information (optional)
Name: _______________________________________________________________________________ Relationship: ________________________________________
First Last
Address: ________________________________________________________________________________________________________________________________________________
Street Apt.
City State Zip
Telephone: ______________________________________________________________________________________________
Applicant Signature
I certify that all the information submitted on this application is true.
Signature of Applicant: _________________________________________________________________ Date: ___________________________________________
Signature of Parent: ____________________________________________________________________
Only needed if Applicant is under 18 years of age
Questions? Please call Behrakis One-Stop Enrollment Services: 978-556-3700.
Date: ___________________________________________
Armative Action and Equal Opportunity Policy: Northern Essex Community College is an armative action/equal opportunity college and does not discriminate on
the basis of race, color, national origin, sex, disability, religion, age, veteran status, genetic information, gender identity or sexual orientation in its programs and activities
as required by Title IX of the Educational Amendments of 1972, the Americans with Disabilities Act of 1990, Section 504 of the Rehabilitation Act of 1973, Title VII of the Civil
Rights Act of 1964, and other applicable statutes and college policies. The College prohibits sexual harassment, including sexual violence. Inquiries or complaints concerning
discrimination, harassment, retaliation or sexual violence shall be referred to the College’s Armative Action and/or Title IX Coordinator, the Massachusetts Commission
Against Discrimination, the Equal Employment Opportunities Commission or the United States Department of Education’s Oce for Civil Rights.
All inquiries concerning application of the above should be directed to the College’s Armative Action/Section 504 Compliance Ocer: Elizabete Trelegan, Human
Resources, Section 504/ADA Compliance; Title IX; Armative Action; Northern Essex Community College, 100 Elliott Street, B-219, Haverhill, MA 01830; Phone: 978-556-3928;
Email: etrelegan@necc.mass.edu
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