Authorization to Release Information
FERPA Release Form
Student Name (Please Print) Student I.D. Number
In accordance with the Family Educational Rights and Privacy Act of 1974 (FERPA), the undersigned
student hereby permits Houston Community College to disclose the information specified below to the
following individual(s) or agency (ies): The student authorizing the release of his/her educational records
must sign & present this form to the appropriate office with a photo ID to verify authenticity of this release.
Name:
Name:
Name:
Name
:
Check the box b
elow to indicate which records you wish to make available:
All Financial Aid Records
(records include: status of file, award and disbursement of funds information,
Satisfactory Academic Progress status, income information, and any other information contained in the
application or financial aid file).
All Academic/Transcript Records (records include: transcripts, admission and registration information,
schedule documentation contained in the academic records).
All Student Account Records (records include: amount for tuition and fees, sources of payment for
tuition and fees, refund information, records hold information as it relates to parking tickets, library fines,
financial aid repayments and any other accounts receivable information contained in student account
records.
Instructor/Classroom Records (records include: 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).
All College Records
Other (Please Specify) ___________________________________________________
Please Note: Records for Counseling and services for Students with Disabilities are considered
medical records and are not covered under FERPA rules. A separate release form must be obtained
from these departments.
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 from the date it is executed until
revoked by me, in writing, and delivered to the Department(s) identified above.
Student Signature Date
Save & email as attachment to vaonline@hccs.edu if you receive error after clicking submit
click to sign
signature
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