Student Service Center
Gander Hall, Room 124
www.maryville.edu/ssc
ssc@maryville.edu
Phone: (314) 529-9360
Fax: (314) 529-9925
Maryville University
An: Student Service Center
650 Maryville University Drive
Saint Louis, MO 63141
Student Signature: Date:
FERPA Authorizaon to Release Student Informaon
In accordance with the Family Educaon Rights and Privacy Act of 1974 (FERPA), 20 U.S. C. § 1232g , Maryville University is
prohibited from releasing nancial or academic records to third pares, including parents or spouses, without this signed
release. Please visit our FERPA website for more informaon - hps://www.maryville.edu/ssc/ferpa-4/.
Student Informaon
Student Name __________________________________________________________
Maryville ID Number or Social Security Number __ __ __ __ __ __ __ __ __
Date of Birth __ __ / __ __ / __ __ __ __
Start Term Fall / Spring / Summer __ __ __ __
Designee Release Informaon
Designee Name(s) __________________________________________________________
Designee Address __________________________________________________________
____________________________ ______ _______________
Designee Phone Number ( __ __ __ ) __ __ __ - __ __ __ __
Relaonship to Student __________________________________________________________
Nocaon to the Student Service Center:
I, ______________________________________, authorize the release of all required and requested informaon as it pertains
(Print Student Name Here)
to my student record as protected by the Family Educaon Rights and Privacy Act (FERPA). This authorizaon is valid through
the duraon of my educaon at Maryville University. If this release of record is no longer applicable I recognize that I must
contact the Student Service Center to amend this request.
Please return this completed form to the Student Service Center in order to allow the release of your informaon to the
individual(s) listed as Designee(s). The address and fax number are located in the header of this form.