FERPA Consent to Release Educational Records
The Family Education Rights and Privacy Act of 1974 (FERPA) states that a student must authorize in writing the
release of her or his educational records to a third party. Please print legibly in ink when completing this form.
Student Name: ________________________________________________________________________
Student ID: ___________________________________________Date of Birth: _____________________
Person(s) to whom you authorize the release of your records: __________________________________
_____________________________________________________________________________________
You can list multiple people. You must provide each authorized person listed with the password you choose below. If they are
unable to provide the password, your records cannot be released.
Password: ____________________________________________________________________________
You are responsible for the security of this password. Protect it from unauthorized parties.
I authorize the release of educational records in the following areas (check all that apply):
Academic Records
Financial Aid
Student Accounts
Granting access to the parties listed does not preclude you from revoking access to any of the parties or record types above, if
done so in writing.
I realize that if I choose to limit access no information will be shared with the people listed above after
the date I select. Access can only be reinstated by completing a subsequent FERPA Consent to Release
Educational Records form.
Student Signature: _______________________________________________ Date: _________________
Form must be submitted in person at the Admissions and Records Office in Houff Building.along with a picture ID. Otherwise a
Notary signature is required.
I am not submitting my form in person. My notary verification is below.
Notary: _______________________________________ Commission Expires: _________________
Return Completed Form to:
Blue Ridge Community College Admissions and Records
One College Lane, P.O. Box 80
Weyers Cave, VA 24486
Office Use Only
BRCC Staff or Faculty Witness: _________________________________________________ Date: __________________________
Person who entered authorization into SIS: _______________________________________ Date entered: ___________________
