Admissions
Revised 10/2020 Address: P.O. Box 270 Winnebago, Nebraska 68071 • Phone: 402.878.2380 • Website: www.littlepriest.edu
Disclosure to Parents of Dependent Students and Consent Form for Disclosure to Parents
______________________________________________________________________________
Student’s First Name Middle Initial Last Name
______________________________________________________________________________
Permanent Street Address City State Zip Code
Under the Family Educational Rights and Privacy Act (FERPA), Little Priest Tribal College is permitted
to disclose information from your education records to your parents if your parents (or one of your
parents,) claim you as a dependent for federal tax purposes. Please indicate whether your parents claim
you as a tax dependent.
Please check the appropriate box:
Yes, I certify that my parents claim me as a dependent for federal income tax purposes.
No, I certify that my parents do not claim me as a dependent for federal income tax purposes.
Signature: ___________________________ Date: _________________
If you are not claimed as a dependent or you do now know whether you are claimed as a dependent for
federal income tax purposes, but you agree that Little Priest Tribal College may disclose information from
your education records to your parents, please sign the following content.
I consent to the disclosure of any personally identifiable information from my education records to my
parent(s), for reasons determined by Little Priest Tribal College as appropriate. This authorization will
remain in effect for the ______________ school year.
Signature ______________________________ Date _____________________
If parents live at same street address, please list both in #1.
1._______________________________ 2.________________________________
Name(s) Name(s)
__________________________________ ___________________________________
Address Address
__________________________________ ___________________________________
City, State, Zip City, State, Zip
__________________________________ ___________________________________
Telephone Telephone
*Students cannot be denied any educational services from Little Priest Tribal College if parents refuse to provide consent*
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