Au
thorization to Release
Student Records under FERPA
Updated: July 6, 2015
For student use
The Family Educational Rights and Privacy Act (FERPA) established in 1974 was enacted to protect students’
personal and academic records. FERPA requires certain protective practices to be in place for personally
identifiable information of all enrolled students.
Instructions
Fill out the information below to allow a third party (such as a parent or legal guardian) permission to speak to
Black Hawk College regarding your academic record.
Student Information
First Name _______________________________ Last Name _______________________________________
Student ID _______________________________
Third-Party Information
Name ____________________________________________
Picture identification (example: driver’s license) of this person is required to release your student information.
The type of information to be released is from academic records (including grades, class schedule, and other
academic information), financial aid records, and finance (student accounts receivable) records.
Please acknowledge below and return to Enrollment Services if you consent for the College to release
information from your educational records to the person listed above.
I consent that Black Hawk College may disclose confidential information from my educational record to the
individual listed above.
Student Signature _________________________________________________ Date __________________
*Signature line may be left blank, and e-signature will be accepted when completed form is sent from a
student’s myBHC email account.
Please Note: This release form will remain valid unless specifically revoked in writing by the student.
Return by email to: registrar@bhc.edu OR Print and return to:
Black Hawk College
Enrollment Services
6600 34
th
Avenue
Moline, IL 61265
Created by Enrollment Services, July 2015.
