Fillable Disclosure of Student Information Consent Form (Walla Walla University)

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Disclosure of Student Information Consent Form (Walla Walla University)

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Disclosure of Student Information Consent Form
The Family Educational Rights and Privacy Act (FERPA) requires consent under most circumstances to disclose information
from a student’s educational records. Consent is voluntary and students are not denied educational services if they do not
provide consent.
Student Name (print)
ID Number
I give permission for:
to disclose my personal information to:
(WWU employee name or department)
(name)
(relationship if applicable)
Summarize the purpose of the information disclosure:
Please list the specific information that can be shared: (i.e. course grades fall term, CommUnity attendance record winter term, etc)
Please identify how the information may be shared:
(i.e. copy of a letter by mail, email message, phone call, etc. provide email, snail
address, phone number, etc.)
Please indicate the time frame for the information disclosure
(maximum of one academic term). This consent is valid for
the dates listed unless the student withdraws their consent by
written notice to the office or person list above.
to:
(Start date)
(End date)
I voluntarily request to the disclosure of personally identifiable information from my educational records at Walla
Walla University as indicated above:
Student Signature
Date
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Disclosure of Student Information Consent Form (Walla Walla University)

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Completed 2 February 2021

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