Name:_______________________________________________________________
Last First MI
The Family Educational Rights and Privacy act (FERPA) of 1974, as amended, seeks to guarantee
both a student’s right of access to education records and the condentiality of student information.
Institutions may not disclose information contained in education records without the student’s written
consent except under certain conditions. A student’s record may be released to parents, guardians or
other third parties by providing a written authorization or consent.
Student Consent for Release of Information
I hereby give my consent for my parent, guardian, or other third party, as name below, to have ac-
cess to my education records. I understand that each individual will need to show a valid photo ID at
time of release to view my records.
Student Signature: __________________________________ Date: _____________________
Parent/Guardian/Third Party (Please Print)
1) ____________________________________ _____________________________
Name Relationship
2) ____________________________________ _____________________________
Name Relationship
3) ____________________________________ _____________________________
Name Relationship
Student Withdrawal of Consent for Release of Information
I hereby withdraw my consent for my parent, guardian or other third party as named above, to have
access to my education records, effective immediately. If I wish to reinstate the consent for release of
information, I understand that I will have to complete another form at that time.
Student Signature: __________________________________ Date: _____________________
Admissions and Records
2277 Napa-Vallejo Highway, Napa, Ca. 94558
707-256-7200 fax 707-256-7219
Student Consent for Release or Withdrawal of Consent for Release of Information
Please print clearly in black or blue ink. All blanks must be lled-in for this form to be considered.
NVC Student ID#
(7 digit number assigned by the college for identication)
Rev. 4/2014
