Authorization to Release Information
FERPA Release Form
First Name
Last Name
Student ID:
In accordance with the Family Educational Rights and Privacy Act of 1974 (FERPA) provides certain rights to students concerning
the privacy of, and access to, their education records. Students may choose to complete this form to allow the release of their
education records to specified third parties. Counseling and services for Students with Disabilities are considered medical
records and are not covered under FERPA.
Instructions for completing this form:
1. The form must be fully completed and signed by the student in person at the Campus Enrollment Services Office with
proper identification. Records cannot be released if any Section of this form is not filled out entirely.
2. Persons who receive access to student records must provide appropriate identification in person and provide the
password associated with this release of records. Privacy regulations prohibit the release of certain information on
the telephone.
3. If the student is unable to sign the FERPA Release form in person, the student will need to submit a FERPA Notary
Form along with the FERPA Release Form and a copy of a valid ID.
4. To revoke a prior approval, complete and sign the Revocation sections at the bottom of this page.
SECTION A: Education records be released (check all that apply):
All Records List Below
Academic/Transcript Information (transcripts, admission & registration information, grades/GPA, academic progress,
enrollment status)
Financial Aid Information (awards, application data, disbursements, eligibility, financial aid academic progress status)
Student Account Information (tuition & fees charges, credits, payments, past due amounts, collection activity)
Instructor/Classroom Records (attendance, progress reports, test and homework scores if available. Please note:
instructors are not required to take attendance or provide progress reports, and retain only those records which make up
the file grade. FERPA pertains to the release of records. Instructors are not required to have conversations about progress
with anyone other than the student).
Veteran Information (VA Educational Benefits)
Other (Please
Specify) ________________________________________
SECTION B: Person to whom access to education records may be provided:
_____________________________________________________________________________________________________
Name of person to whom your records may be released (Note: use an additional form for each person granted release)
Password for access to records (must not include any part of SSN or DOB) ____________________________________
Relationship to Student
SECTION C: Duration of release (check one):
Term-based: This authorization is active only for the current academic term: __________________
Open-ended: This authorization is active until revoked in writing and in-person.
Authorization and Signature (required for all submitted forms):
I understand the information may be released orally or in the form of copies of written records, as preferred by the
requester. This authorization will remain in effect for the duration of the release or revoked by me via this form and will be
applicable to all offices of Houston Community College.
_______________________________________________________________ ____________________________
Student’s Signature Date
Revocation (complete only if removing access):
I choose to revoke a previously granted Consent to Access of Student Records for the individual listed in Section B
effective the date signed here. Signature: ________________________________________ Date: ____________________
Rev: April 2018
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome