800 Mickelson Drive
Rapid City, SD 57703-4018
605-718-2400 Fax: 605-394-2204
Toll Free: 1-800-544-8765
www.wdt.edu
AUTHORIZATION TO
RELEASE INFORMATION
Third Party
Student’s Name: ________________________________ Student ID#:___________________
(Not Social Security #)
In accordance with the Family Educational Rights and Privacy Act of 1974 (FERPA), Western
Dakota Tech (WDT) must receive a student’s authorization to permit WDT to release academic
and financial information to third parties.
Students requesting WDT to provide academic information, financial information, FAFSA
information or to complete funding authorization documents to a third party agency or third party
funding agency (not including the US Department of Education or Veteran Affairs) must submit
this completed Authorization to Release Information form to the Registrar Office. The
submission of the completed form is required before WDT can provide the information to any
third party agency or third party funding agency on behalf of the student. Release of FAFSA
information may be more limited as determined by law.
The undersigned student hereby permits Western Dakota Technical Institute to release academic
and financial information to the following third-party funding agencies:
Agency: ____________________________________________
Agency: ____________________________________________
Agency: ____________________________________________
This consent to release information shall remain in effect until revoked by the student, in writing,
and delivered to Western Dakota Tech Registrar’s Office. This authorization may be rescinded at
any time by the student submitting a written statement to WDT’s Registrar’s Office.
I have read and understand the contents of this consent form pertaining to the Family
Educational Rights and Privacy Act of 1974.
Student’s Signature _______________________________________ Date ________________
Internal use: Received by: ________________________
Initials Date
Permissions Updated by _________ (initials) on ________________ date
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