Admissions & Records
College of the Siskiyous, 800 College Ave., Weed, CA 96094
Phone: (530) 938-5500 - Fax: (530) 938-5367 Email:
Parent Verification of Student Dependency and Request for Educational Record Information
Note: For parental access to student information without a release from the student
To: College of the Siskiyous Office of the Registrar
(Name of Parent(s) Requesting Information)
Address: Phone:
City: State: Zip Code:
The Family Educational Rights and Privacy Act of 1974 (FERPA), as amended, is a Federal law that protects the privacy
of student education records. FERPA requires that a student provide written consent for a disclosure of personally
identifiable information from education records unless the circumstances meet one of the exceptions to the “prior written
consent” rule that is specified in the law and its implementing regulations. Under those exceptions, as implemented by the
College, the College may, at its sole discretion, disclose information from a student’s education records without the
student’s written consent to Parents (the term “Parents” includes a natural parent, a guardian, or an individual acting as a
parent in the absence of a parent or guardian) of a dependent student (as defined in section 152 of the Internal Revenue
Code of 1986). The College is not obligated to nor will it disclose any financial information about one parent to the other
parent. A copy of the Parent’s most recent Federal tax return must be attached to and submitted with this
verification/request form.
Identify the Dependent-Student (“Student”):
Student’s Full Name:
Student ID (S#): Date of Birth (MM/DD/YYYY):
Initial the following:
I/We certify that the above-named student is my/our dependent and that I/we claimed him/her as a dependent on
a federal income tax return for the most recent Tax Year of . A copy of my/our federal income tax return for
that year is attached. I/we also certify that we intend to claim the above-named student as a dependent on a federal
income tax return for the current tax year. I/We understand a new form will need to be submitted on or before April 15
each year after the most recent federal income tax return in submitted.
I/We further certify that I/we have never been arrested for domestic or family violence against the dependent-
student; and that I/we am/are not aware of any court or administrative order, state or federal law or legally binding
agreement that revokes or otherwise abrogates any right I/we may have as a Parent.
I/We agree to indemnify the College of the Siskiyous and its trustees, officers, agents, and employees from any
and all claims and damages arising from the College’s disclosure of information contained in the Student’s education
record that is made as a result of this Verification.
We hereby request the following record(s)/information from my dependent-Student’s education records:
For the following purpose(s)
Read Before Signing: By completing and signing this form, you acknowledge your understanding that the information
contained in this form will be used by the College of the Siskiyous to determine your eligibility to receive
records/information made confidential by federal law. You further acknowledge that you understand that it is a criminal
offense under state and federal law to knowingly make a false entry in this form; to make, present, or use this form with
knowledge of its falsity and with intent that it be taken as a genuine governmental record; and to make, present, or use
this form with knowledge that the information provided by you is false.
(Signature of Requestor-Parent) (Date)
(Signature of Requestor-Parent) (Date)