Updated 1/2014
CERTIFICATION AND SIGNATURE
Eastern Wyoming College
3200 West C Street
Torrington, WY 82240
Fax: 307-532-8222
Eastern Wyoming College
Authorization to Release
Information/Records
The Family Educational Rights and Privacy Act (FERPA) prohibits an educational institution from releasing confidential,
non-directory information about a student without his/her consent. Students can waive this right for a third party, including
a parent, guardian, or spouse, to have access to this information by completing written authorization, such as this form.
PLEASE NOTE: Students are not required to complete or submit this form. EWC provides this form for the convenience of
our students only. Releasing any information is THE STUDENT’S decision based on his/her needs.
______________________________________________________________ ________________________________________
FULL LEGAL NAME: Last First M.I. EWC Student ID Number
______________________________________________________________ ________________________________________
Address (include apartment number) Social Security Number (Last 4 digits)
______________________________________________________________ ________________________________________
City, State, Zip Phone Number (Include area code)
I hereby authorize Eastern Wyoming College and/or its employees to release confidential information such as grades, academic
progress reports, financial aid, disciplinary actions, and financial account information to the person(s)/ agency(ies) listed herein. This
authorization shall be considered as a waiver of any and all my rights and/or privileges as provided under the FERPA, as amended.
I understand that my confidential information will only be released upon receipt of a request for specific information and that I may
cancel this Authorization at any time.
I authorize the following to be released (check all that apply):
Business Office Includes student account information such as billing information, amounts due, sources of payment,
refund information and any other accounts receivable information
Financial Aid Office Includes file status, award and disbursement information, Satisfactory Academic Progress status,
income information, and any other information in the financial aid file
Admissions/Records Includes application status, assessment scores, transcripts, registration/ info, grades, attendance,
Academic Progress status, residency information, and any other documentation in academic record
Student Affairs Includes disciplinary records, academic dishonesty, conduct or behavior records
All of the above
Other: _______________________________________________________________________________________________
Counseling and/or disability records are considered medical records and are not covered under FERPA rules. A separate release form
must be obtained to release information from those records.
Persons to whom my information may be released:
Name: ___________________________________________________________ Relationship: _______________________________
Name: ___________________________________________________________ Relationship: _______________________________
Name: ___________________________________________________________ Relationship: _______________________________
By signing this form, I authorize EWC to release and disclose information from my education records as specified. This authorization
remains in effect until I revoke it in writing or by completing the reverse side of this form.
Student Signature: ____________________________________________________ Date:________________________
