AuthorizationtoReleaseInformation
ThisformservesasstudentconsentforrecordstobereleasedtoParent(s),LegalGuardian(s),Other
tuitionprovidersorotherindicatedindividuals:
Student’sName:RamID:
_________________________________________ ______________________
PLEASEREAD:
InaccordancewiththeFamilyEducationalRightsandPrivacyActof1974(FERPA),theundersigned
studentherebypermitsAlbanyStateUniversitytodisclosetheinf
ormationspecifiedbelowtothe
followingindividual(s)oragency(ies):
Name:________________________________________________________________
Name:________________________________________________________________
Name:________________________________________________________________
Name:________________________________________________________________
Thisconsentshallbevalidthroughoutthestudent’senrollmentatAlbanyStateUniversityand
thereafter,butmaybemodifiedorrescindedbythestudent.Therecipientofthestudent’sinformation
(asname
donlinesabove)agreethattheyshallnotdisclosethespecifiedinformationtothirdparties
withouttheexpressconsent/authorizationofthestudent.
INFORMATIONTOBERELEASED:
ThefollowinginformationfrommyrecordsatAlbanyStateUniversitymaybedisclosedtotheabove
specifiedperson(s):
____Schedules,GradesandAcademicS
tanding
____DisciplinaryRecords
____TuitionandFeeStatements
____FinancialAidInformation
____Allrecordsorinformationpertainingtostudent
____Other,pleasespecify(_____________________________________________________________)
IhavereadandunderstandthecontentsofthisconsentformpertainingtotheFamilyEducational
RightsandPrivacyActof1974.
Student’sSignature:
Date:
__________________________________________ ___________________
05/15/2013
Form Version #1
Please return your completed
form to the Office of
Academic Services & Registrar
in ACAD 283 or via email at
asr@asurams.edu
click to sign
signature
click to edit