S:\Registrar\Forms\FERPA 2018
FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA)
INFORMATION RELEASE FORM
PLEASE CLEARLY PRINT ALL INFORMATION
In compliance with FERPA, Southwestern University cannot release a student’s educational record to any person unless
authorized by law or unless the student consents to the disclosure in writing.
Student’s Name:
Last First Middle
Student ID:
I hereby give my voluntary, written consent for Southwestern University to release and discuss my educational records as
indicated below upon request to the person(s) listed below in written, oral, and electronic formats.
Furthermore, I understand this consent covers each semester of my attendance, remaining in effect until rescinded by me in
writing.
Finally, I hereby release Southwestern University, its agents, employees and officers from any and all liability which may
result from the release of records pursuant to this consent.
I authorize Southwestern University personnel to release my final grades each semester to the person(s) below. This
authorization is limited to the mailing of final grades, which must be requested at the end of each semester.
I authorize Southwestern University personnel to release/discuss my student account/financial obligations, merit
scholarships, and financial aid upon request to the person(s) listed below.
Student Signature: Date:
#1 – AUTHORIZED PERSON Please select one: Add Remove Update email
Last Name: First Name:
Address:
City: State: Zip Code:
Phone: Email:
Relationship to Student:
#2– AUTHORIZED PERSON Please select one: Add Remove Update email
Last Name: First Name:
Address:
City: State: Zip Code:
Phone: Email:
Relationship to Student:
If you wish to list additional persons, please use the back of this form to write their information.
Return completed forms to the Center for Academic Success and Registrar.
Center for Academic Success and Registrar ● PO Box 770 ● Georgetown, TX 78627
Phone: 512-863-1952 ● Fax: 512-863-1685 ● registrar@southwestern.edu
