INDIAN RIVER STATE COLLEGE
OFFICE OF STUDENT RECORDS
(772) 462-7460
Authorization for Release of Educational Records
Student Accessibility Services
in accordance with Family Educational Rights and Privacy Act (FERPA – 34 CFR Part 99)
Student ID#: Date of Birth (Month/Day/Year):
Student’s Printed Name: Last First Middle
Authorization Information: I authorize Indian River State College (IRSC) to release information as
indicated below: Name of Authorized Person or Persons
Last Name First Name Middle Name
Relationship to Student
Last Name First Name Middle Name
Relationship to Student
Type of Information Access
Academic: (including, but not limited to) grades, GPA, test results, enrollment information, course
schedule
Financial Aid: (including, but not limited to) satisfactory academic progress, FAFSA Information,
award amounts
Student Account: (including, but not limited to) account balances, account charges, billing, payments
Accessibility: (including, but not limited to) documentation, diagnosis, medications, symptoms,
treatment
Authorization Certification - In compliance with FERPA regulations, IRSC is prohibited from providing certain
educational records to a third party, including the parent or spouse of a student, without the expressed consent
of the student. This authorization is for access, and is not intended as permission for the authorized person(s)
to conduct transactions on behalf of the student.
To obtain access to educational records for the above-named student, I understand that 1) This form must be
submitted with photo ID for both student and authorized person(s), and 2) Each time I make a request for
information, I must appear in person with a photo ID, or FAX or email my request accompanied by a copy of a
signed photo ID to IRSC Records at (772) 462-4699 or records@irsc.edu.
Authorized Person Signature
(Optional) Email Address Authorized for Communication
Authorized Person Signature
(Optional) Email Address Authorized for Communication
I authorize the release of the specified records to the person(s) named above any time a request is made
while I am enrolled at IRSC. I understand that this authorization will remain in effect until completion of the
Cancel Request below.
Student’s Signature Date Authorized
Cancel Request
I request that the above Authorization for Release of Information be cancelled.
Student’s Signature Date Cancelled
FOR OFFICE USE ONLY: Records Specialist Date Entered
Office Use Only
Received by:
Campus:
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