Disclosure to Third Party of Students and Consent Form for Disclosure to Third Party
10/2020 Address: P.O. Box 270 Winnebago, Nebraska 68071 • Phone: 402.878.2380 •Website: www.littlepriest.edu
______________________ ______________ ___________________ ____________
Student’s First Name Initial Last Name ID #
___________________________________________________________________________
Mailing Address Street Address City State Zip Code
Under the Family Education Rights and Privacy Act (FERPA), Little Priest Tribal College is permitted to
disclose information from your education records to a third party only if the student consents in writing.
Please indicate what information may be disclosed and to whom it may be disclosed.
Please check the appropriate box.
The following information may be disclosed to the named third party.
___ Financial Aid Information ___ Business Office Information
___ Academic Information ___ Bookstore Charges
___ Application Information ___ Other; _____________________
Do not release any information to a third party.
I consent to the disclosure of any personally identifiable information from my education records to the
following third party for reasons determined by Little Priest Tribal College as appropriate. A new form
must be completed for each school semester.
Signature ___________________________________ Date ________________
The following third party of parties may receive information concerning the above name records.
1.______________________________ 2._____________________________
Name(s) Name(s)
________________________________ ______________________________
Address Address
________________________________ ______________________________
City, State, Zip Code City, State, Zip Code
________________________________ ______________________________
Telephone Telephone
*Students cannot be denied any educational services from Little Priest Tribal College if the refuse to provide
consent
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