FERPA RELEASE STU INFO | MARCH 2019
BELOIT COLLEGE
FERPA C
ONSENT TO RELEASE STUDENT INFORMATION
TO: __________________________________________________________________ (Name of
Beloit College Official and Department that will be releasing the educational records)
Please provide information from the educational records of ____________________ [Name of
Student requesting the release of educational records] to: _________________________________
[Name(s) of person to whom the educational records will be released, and if appropriate the
relationship to the student such as “parents” or “prospective employer” or “attorney”]
(Note: this Consent does not cover medical records held solely by Student Health Services or the
Counseling Center – contact those offices for consent forms.)
T
he only type of information that is to be released under this consent is:
_____ transcript
_____ disciplinary records
_____ recommendations for employment or admission to other schools
_____ all records
_____ other (specify) _____________________________________________________
The information is to be released for the following purpose:
____ family communications about university experience
____ employment
____ admission to an educational institution
____ other (specify)______________________________________________________
__________________________________________________________
__________________________________________________________
I understand the information may be released orally or in the form of copies of written records, as
preferred by the requester. I have a right to inspect any written records released pursuant to this
Consent (except for parents’ financial records and certain letters of recommendation for which the
student waived inspection rights). I understand I may revoke this Consent upon providing written
notice to [Name of Person listed above as the Beloit College
Official permitted to release the educational records]. I further understand that until this revocation is
made, this consent shall remain in effect and my educational records will continue to be provided to
[Name of Person listed above to whom the educational
records will be released] for the specific purpose described above.
Name (print)_____________________________
S
ignature________________________________
Student ID Number________________________
Date_____________________________________
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