FERPA
A
UTHORIZATION TO RELEASE INFORMATION FROM ACADEMIC RECORDS
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TO BE COMPLETED BY STUDENT:
Pursuant to the provisions of the Family Educational Rights and Privacy Act of 1974, as amended (FERPA), I give my
consent to authorized representatives of the University of Central Arkansas for the release of my academic records and
any and all personally identifiable information contained therein to the below listed individual. I understand that this
authorization will remain in effect until I rescind it in writing. I understand that I have the right to rescind this
authorization at any time.
Student Information Identity of Person Authorized to
Receive Academic Information
Effective:(circle) Fall
Spring
Summer
Year:
Relationship to Student:
Student Name
Name
ID Number
Student Signature Date
Address
City
State
Zip
TO BE COMPLETED BY PERSON(S) AUTHORIZED TO RECEIVE ACADEMIC INFORMATION:
In accordance with the consent of the above student, I accept full responsibility for any and all information contained in
the academic record that may be released to me, and agree to abide by the following procedures and provisions:
• All requests for information will be submitted by me in writing or on a form supplied by the University.
I understand that academic information may not be discussed over the telephone
. Initial
• The University may charge its normal fee (if any) for the services requested and provided. Initial
• The student may rescind the authorization at anytime. I understand the University is not responsible for the non-release
of future academic information should the student rescind this authorization.
Initial
Signature: Date Signed:
For information about the Family Education Rights and
Privacy Act of 1974, as amended,
direct inquires to:
UCA Registrar Office
Harrin Hall, Suite 224
Conway,
Arkansas 72035-0001
Telephone: (501) 450-5200
FAX: (501) 450-5734
Return completed forms to this address
FOR REGISTRAR OFFICE USE ONLY
DO NOT WRITE IN THIS SPACE
Recorded By
Date:
COPY TO: Person Authorized to receive Academic Information. This is to acknowledge receipt of authorization for
you to receive academic record information at the University of Central Arkansas for the student listed on this form.
Observe the procedures outlined in the agreement section when you request information.
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