ALVIN COMMUNITY COLLEGE
FERPA Limited Release Form
(Form must be completed at Admissions Office)
Student Name ____________________________________ Student ID ________________________
Student SSN _________/_____/________
Alvin Community College is required to follow the guidelines set forth in the Family Educational Rights and
Privacy Act (FERPA). This act mandates that we safeguard and maintain the privacy and confidentiality of all
student records. If you have a person or organization to who you want non-directory information released, you
must complete this form. In the event you wish to cancel this release, you must do so in writing with the
Registrar=s Office. Alvin Community College will not be responsible for disclosure of information made before
written cancellation is received by the Registrar=s Office.
By completing the list and signing below, you give us permission to discuss your student records with someone
other than yourself (i.e. spouse, parent, organization).
Proof of ID will be required from you when submitting this form. Proof of ID will also be required from the
individual(s) to whom access has been granted when requesting information about you. Request of information
about you can only be made in person. No information will be disclosed over the phone.
I hereby authorize Alvin Community College, Registrar=s Office and other pertinent college officials to
release non-directory information about me to the person(s) listed below:
Name of Individual or Organization Relationship
____________________________________ _____________________________
____________________________________ _____________________________
____________________________________ _____________________________
Disclosure of ‘non-directory’ information allowed as marked below: (check all that apply)
___Attendance in course(s)
___Grades in course(s)
___Teacher ratings/observation in course(s)
___Extracurricular Activities/Projects
___Scores on placement test(s)
___Interest Inventory results
___Financial Aid Information processing (grants, scholarships, loans)_____________________________
____________________________________________________________________________________
___Business Office transactions (tuition/fees balance, financial student restrictions)__________________
____________________________________________________________________________________
Student=s Signature____________________________________ Date____________________________
Form must be completed in person: Admissions Office, A-Building
Verified ID by: Distribution: Registrar’s Office/Student’s Record
click to sign
signature
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