FERPA Release Form
9/16/08 (rev. 12/18/19 kc)
Last Name ______________________ First Name _________________________ SID ______________________
The Family Educational Rights and Privacy Act (FERPA) is designed to protect the privacy of a student’s
educational records. These records may include academic, financial aid, scholarship, athletics, veterans,
and billing/account information. Records will not be released without prior written consent from the
student. Certain information, defined as directory information, may be released without the prior consent
of the student. All sections must be completed for release to be valid.
Information to be Released (or revoked see below) Duration of this Authorization
lete access to all records with no exceptions
Academic records
Financial Aid, grants or scholarships records
Until Date _________________
Until I graduate or am no longer enrolled/leave
Until I revoke FERPA Authorization
Billing records
Attendance records
Other, please specify: ____________________________________________________________________________________
You are required to create a code word that you share only with the individual you have designated.
The individual must know this code word in order to gain access to the records you have granted.
Code Word: _____________________
Release to (Recipient): Revoke to (prior recipient):
Organization Organization
Name Name
Phone Number Phone Number
Relationship to Student Relationship to Student
By signing this form, I authorize Grays Harbor College to release and disclose information
from my educational records as specified for the period of time indicated. This release
remains in effect as specified or until I revoke this authorization in writing to the Student
Records Office.
Student Signature Date
For internal use only: Disclosure Information Checklist
Requested by the student in person with ID
Or Requested by the student via:
Mail Fax Online (if not in person, must further identify student)
Date ______________ Staff ______________
Date ______________ Staff ______________
Form completed, signed and dated
Recorded in SMS
Entered into scanning
Copy to:
Financial Aid Business Office