Columbia State Community College
Family Educational Rights and Privacy Act (FERPA)
Student Release of Confidential Information Form
This form allows students to authorize the release of confidential academic, financial aid, discipline, and student account information
otherwise protected by the Family Educational Rights and Privacy Act (FERPA) to designated persons.
I (the student) do hereby authorize Columbia State Community College (CSCC) and/or its employees to release my confidential
academic, financial aid, discipline and any student financial account information, including academic progress reports and grades
when available, to the person(s) named in the following information. This release does not apply to other information (counseling and
health) protected by FERPA.
Authorization is valid as long as I am enrolled at CSCC or until cancelled in writing by me. I understand I have the right to
receive a copy of such records upon request. I acknowledge that I may revoke this “Student Release of Confidential Information” in
writing at any time by presenting such authorization in person to the Records Office. I also acknowledge and agree that disclosure of
records and /or information made prior to my written revocation shall not constitute a violation of my right to privacy under federal
and state law. To cancel this release, the student must submit the written cancellation request in person and must be prepared to
present a valid photo ID to the Records Office in the Jones Student Center, Room 112.
Student Name (Please Print)
Education records to be released (check all that apply):
☐ Financial Aid/Attendance Records
☐ Admissions Documents
☐ Enrollment Status
☐ Grades & Transcript Information
☐ Final Grades
☐ Conduct/Discipline
☐ Early Alerts
☐ Academic Standing
☐ Student Business Accounts
☐ Graduation Status
☐ All Records Listed Above
Name of person(s) (other than self) authorized to receive or Personal Identification Number request information. List
Primary recipient first.
IMPORTANT: The following information must be completed to assist CSCC staff in identifying the non-student recipient
of information when he/she calls to request information by telephone.
Last 4 of
Recipient’s
SSN
Student’s Signature: _______________________________________ Date: _____________________________
Campus Receiver (Print Name): __________________________________ Date: _________________________
For more information regarding CSCC’s FERPA policy, please visit https://columbiastate.edu/policies-procedures/privacy.html.
