AUTHORIZATION FOR RELEASE OF PERSONALLY
IDENTIFIABLE STUDENT INFORMATION
Student consent is required for the release of personally identiable information such as semester grades, academic record, class sched-
ule, current academic standing, student ID and/or Social Security number.
Students may consent to the release of personally identiable information to others by completing this form. The Family
Educational Rights and Privacy Act of 1974 (FERPA) allows disclosure of personally identiable information without student consent to:
Florida Institute of Technology § Oce of the Registrar § 150 West University Boulevard, Melbourne, FL 32901-6975 § 321-674-8115 § Fax 321-674-7827
Oce of the Registrar Use Only
Operator Initials _________________________________
Date Processed__________________________________
RGR-460-0220
§ certain government agencies/ocials,
§ sponsoring agencies,
§ outside contractors performing a service for the institution that the institution would otherwise perform for itself,
§ National Science Foundation surveys as authorized by Congress,
§ subpoenas/court orders, select law enforcement agencies, and
§ selected school ocials on a need to know basis who have dened legitimate educational interest in
such records.
This request will remain in eect indenitely, until the student named below noties the Oce of the Registrar otherwise
in writing.
I give permission for the individual(s) named below to request in writing copies of my academic grades and transcript
(fee required for ocial transcript), nancial status, payment information and other personally identiable information
contained in my university records. University policy requires a written request to obtain these documents.
Student Name ____________________________________________________________________ Student ID Number _____________________________
Last name First name
o Yes, I authorize the release of information to the parties listed below:
Third Party Name
________________________________________________________________ _______________________________________________
Relationship
Third Party Name ________________________________________________________________ _______________________________________________
Relationship
Student Signature _______________________________________________________________ Date __________________________________________
