Understanding your rights: In compliance with FERPA, the Federal Family Education Rights and Privacy Act of
1974 as amended, West Valley College (WVC) is prohibited from providing your confidential information to any third
party including parents, spouse, guardian, etc. without a signed release.
This information includes, but is not limited
to, all student billing items, awarded financial aid, enrollment status and other various student information. FERPA
allows schools to release Directory Information without prior consent unless a student specifically requests directory
information not to be shared.
Authorization for Release of Non-Directory Information
More information on FERPA can be located at:
http://westvalley.edu/services/financialaid/ferpa.html
Section A. Student Information
Student Name (last, first, middle initial)
Permanent Address (street, city, zip)
)
Section B. Authorization of the Release of Information
I authorize the release of information between West Valley College representative:
Name (last, first, middle initial)
Name (last, first, middle initial)
Date of Birth (month/day)
Address (Only if different from above)
)
Name (last, first, middle initial)
Date of Birth (month/day)
Address (Only if different from above)
)
Section C. Information to be Released – Select one or more of the following
Student Account Information
(tuition and fees,
payments, credits and holds )
Financial Aid
certain information may only be obtained by a student
Academic Record and Other Student Information
Enrollment Verification
Academic Transcript
Class Schedule (Instructor / Location / Units)
All
Educational Records*
Other: ________________________
Note: this authorization does not permit the release of
education records that contain medical information
unless/until the student signs a specific authorization for
the release of medical information in compliance with the
Cali
fornia Confidentiality of Medical Information Act
I understand that I am authorizing West Valley College to release the selected confidential information to the party(s)
listed above.
This authorization does not permit the third party to make any changes.
tudent’s original signature is required. Copies and faxes will not be accepted. Form must be submitted in person or have
ed a copy of student’s valid government-issued photo identification (ID), such as, but not limited to, a driver’s license,
-issued ID, or passport.
I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance
thereon. I also understand that I have the right to receive a copy of this authorization.
This consent expires one year from the date it
was signed unless otherwise indicated_______________________________
Student’s Signature (Required)
