Course Reserves Student Release Form
Student Information
Student Name: ________________________________________
Title of Work: ________________________________________
Instructor and Class Requesting Use of Students Academic Product
Instructor Name: ________________________________________
Course Name: ________________________________________
Department: ________________________________________
Policy and Waiver
Students papers, projects, and other academic products, whether they be in printed or electronic formats, are granted and
retain copyright protection as soon as the works are fixed in some tangible form. Students’ papers, projects, and other
academic products may also constitute components of their respective academic records, and under the guidelines outlined
by the Family Educational Rights and Privacy Act (FERPA), are subject to state and federal privacy protection laws. Thus,
the Course Reserves Department at Indiana University Southeast Library will only accept students’ papers, projects, and
other academic products, either in print or electronic format, if formal written permission is granted acknowledging the
following irrevocable permissions and waivers:
1. I,_______________________________, as the author or creator of the aforementioned paper, project, or other
academic product, hereby grant express permission to Indiana University Southeast Library and the Indiana
University Board of Trustees to have it placed on print or electronic reserve for its use by students in the course
identified above; or, in a similar or closely related course offered by Indiana University Southeast.
2. Indiana University Release of Student Information Policy (http://policies.iu.edu/policies/categories/academic-
faculty-students/university-student-services-systems/USSS-05-release-student-information.shtml), in addition to
local, state, and federal laws, may define and protect student records and other privacy interests relating to the use
and release of productions arising out of or prepared for educational purposes. By signing below, I am authorizing
the release of the academic product identified above for the purposes set forth in Paragraph 1, and I am
relinquishing and waiving any and all claims that may arise under statutory or common law protections as a result
of the use of this academic product for these defined purposes.
Student Signature: ________________________________________ Date: ___________________
Questions: Please Contact
Christopher Proctor
Course Reserves Assistant
University Library
(812) 941-2486
clprocto@iu.edu
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome