The Family Educational Rights and Privacy Act (FERPA) of 1974, as amended, is a federal law designed to
protect the privacy of student education records. However, there are instances when a parent, guardian,
employer, or other interested party requests information from a faculty or staff member about a
student. This form is to be used by students who wish to waive their rights of nondisclosure of the
specified educational records and information under federal law only as to the person specifically listed
I, undersigned, hereby authorize Delta State University to release the following confidential
educational records and information:
(Provide detailed description of records/information to be disclosed.)
To the recipient below:
I understand further that (1) I have the right not to consent to the release of my education records; (2) I
have the right to receive a copy of such records upon request; and (3) that this consent shall remain in
effect until revoked by me, in writing, delivered to Delta State University, but that any such revocation
shall not affect disclosures previously made by Delta State University prior to the receipt of any such
written revocation.
Student Signature Date
a hard copy with original signature to the Registrar’s Office, Kent Wyatt Hall 152, Cleveland,
MS 38733.
Name (Last, First, M)
DSU ID or Last 4 digits of SSN
Birth Date
Name (Last, First, M)
Relationship To Student
For The Purpose Of
Consent to Release Academic Information