March 2013
C
ONSENT FOR RELEASE OF INFORMATION FROM EDUCATION RECORDS
FERPA restricts the kinds of information that can be provided about a student. Therefore, students
who request a letter of reference or a telephone reference from a faculty or staff member must
authorize the release of information from their education records. Students can do this by completing
this form and providing a signed copy to the faculty or staff member providing the reference.
Student Name: _______________________________________________________________WID:___________________________
I request that __________________________________________________________________________________________________
Name(s) of Faculty or Staff Member(s), or Department
serve as a reference for me.
The purpose(s) of the reference are (check all that apply):
Application(s) for employment
Scholarships and/or awards
Admission to another educational institution
Other (please specify)__________________________________
The reference may be given in the following form(s) (check one or both):
Written Oral
I authorize the above-named person(s) to provide an evaluation of any part of my academic
performance, whether based on personal observation or on my education records at Winthrop
University and to release information from my education records, including my grades, GPA, any
information pertaining to my education at other institutions I have previously attended, and
employment at Winthrop. I authorize release of this information and reference or evaluation to
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
(List specific individuals and/or entities. For example, write the name of a prospective employer or
write “all prospective employers,” “all educational institutions to which I seek admission,” or “all
individuals and/or entities considering me for a scholarship or award.”)
I understand that, under the Family Educational and Privacy Rights Act (FERPA), I have the right
not to consent to the release of my education records. I release Winthrop University, its employees
and the person(s) providing the above-described reference or evaluation from all claims and
liability for damages that may result from their compliance with this request.
By initialing here, ___________, I waive my right to review a copy of any reference by the above-
named person(s) at any time in the future.
This consent will remain in effect until revoked. A copy of this consent shall have the same force
and effect as the original.
Student signature: ________________________________________________________________
Date:____________________
