Authorization to Release Education Records Form
v.3 6.25.18
AUTHORIZATION TO RELEASE EDUCATION RECORDS TO THIRD PARTIES
Subject to certain exceptions, the Family Educational Rights and Privacy Act (FERPA) requires a student to provide CCAC with written
consent before it discloses personally identifiable information (“PII”) from the student’s education records to a third-party. This
includes requests to release or discuss PII to or with a parent, attorney or other representative. The written consent must specify the
record(s) to be released; state the purpose of the disclosure; and identify the person(s) to whom disclosure may be made. A record
of any written authorizations given will be maintained in the education record. In order to authorize CCAC to release PII from your
education records, you must complete all fields listed on this form, sign and date it, and return the form to the Office for Registration
and Advisement for the campus at which you are enrolled or, in the case of official transcripts, to the College’s Registrar. By completing
and signing this form below, you acknowledge that you understand that you have the right to (1) not consent to the release of your
education records; (2) inspect any education records released pursuant to this authorization; and (3) revoke this authorization at any
time by delivering a written revocation to the College. Please see the College’s FERPA information page (www.ccac.edu/ferpa
) and
the College’s Board Policy and Administrative Regulations Manuals for additional information.
STUDENT NAME (Last, First, Middle Initial):
STUDENT ID NO:
RECIPIENT INFORMATION:
Name: _______________________________________________
Relationship to Student: _________________________________
Street Address: ____________________________________________
City/State: ________________________ Zip Code: ______________
PURPOSE OF DISCLOSURE:
Family Communications
Employment
Admission to an Educational Institution
Litigation
Other (please specify):
DESCRIPTION OF RECORDS TO BE RELEASED (check all that apply):
Academic Information (transcripts, GPA, registration,
academic progress, enrollment status)
Financial Aid Information (awards, application data,
disbursements, eligibility, SAP status)
Student Account Information (billing statements, charges,
credits, payments, past due amounts; to include pending and awarded aid)
Other (please describe):
DURATION OF AUTHORIZATION:
This authorization will remain effective (please check one):
Indefinitely, and until revoked by me in writing
From the date of this authorization until: ____ /____ / ________
(mo) (date) (year)
STUDENT SIGNATURE:
DATE:
For Office Use Only:
Date Received: _________ Date Scanned: __________ Date Processed: _________ Staff Initials: __________
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