Fillable Consent to Disclose Educational Records (Rider University)

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Consent to Disclose Educational Records (Rider University)

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Registrar’s Office
2083 Lawrenceville Road
Lawrenceville, NJ 08648-3099
Phone: 609-896-5066
Fax: 609-895-5447
Consent to Disclose Educational Records
I ___________________________________________ currently or previously enrolled as a student at
Rider University consent to disclosure of my educational records for the purpose of:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
This information can be released to:
_____________________________________________________________________________________
_____________________________________________________________________________________
I understand that (1) I have the right not to consent to the release of my education records, (2) I have the
right to inspect any written records released pursuant to this consent, and (3) I have the right to revoke
this consent at any time by delivering a written revocation to the University Registrar.
By signing this waiver, I agree to hold Rider University or any of its agents or employees free from
liability for the disclosure of my educational records.
Signed: ______________________________________________ Date: _________________________
Bronc ID or last 4 digits for SSN: _________________________
Current Address: ______________________________________________________________________
_____________________________________________________________________________________
Telephone Number: ____________________________________
Completed form should be returned to the Registrar’s Office, Fine Arts 117
Rider University, 2083 Lawrenceville Road, Lawrenceville, NJ 08648-3099
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Consent to Disclose Educational Records (Rider University)

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Completed 1 February 2021

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