Student Service Center
Gander Hall, Room 124
www.maryville.edu/ssc
ssc@maryville.edu
Phone: (314) 529-9360
Fax: (314) 529-9925
Maryville University
An: Student Service Center
650 Maryville University Drive
Saint Louis, MO 63141
Student Signature: Date:
FERPA Authorizaon to Release Student Informaon
In accordance with the Family Educaon Rights and Privacy Act of 1974 (FERPA), 20 U.S. C. § 1232g , Maryville University is
prohibited from releasing nancial or academic records to third pares, including parents or spouses, without this signed
release. Please visit our FERPA website for more informaon - hps://www.maryville.edu/ssc/ferpa-4/.
Student Informaon
Student Name __________________________________________________________
Maryville ID Number or Social Security Number __ __ __ __ __ __ __ __ __
Date of Birth __ __ / __ __ / __ __ __ __
Start Term Fall / Spring / Summer __ __ __ __
Designee Release Informaon
Designee Name(s) __________________________________________________________
Designee Address __________________________________________________________
____________________________ ______ _______________
Designee Phone Number ( __ __ __ ) __ __ __ - __ __ __ __
Relaonship to Student __________________________________________________________
Nocaon to the Student Service Center:
I, ______________________________________, authorize the release of all required and requested informaon as it pertains
(Print Student Name Here)
to my student record as protected by the Family Educaon Rights and Privacy Act (FERPA). This authorizaon is valid through
the duraon of my educaon 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 If this release of record is no longer applicable I recognize that I must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 informaon to the
individual(s) listed as Designee(s). The address and fax number are located in the header of this form.
