Fill - Free fillable FERPA-Authorization - FERPA Authorization PDF form



AuthorizationtoReleaseInformation

ThisformservesasstudentconsentforrecordstobereleasedtoParent(s),LegalGuardian(s),Other

tuitionprovidersorotherindicatedindividuals:

Student’sName:RamID:

_________________________________________ ______________________

PLEASEREAD:

InaccordancewiththeFamilyEducationalRightsandPrivacyActof1974(FERPA),theundersigned

studentherebypermitsAlbanyStateUniversitytodisclosetheinf

ormationspecifiedbelowtothe

followingindividual(s)oragency(ies): 

Name:________________________________________________________________

Thisconsentshallbevalidthroughoutthestudent’senrollmentatAlbanyStateUniversityand

thereafter,butmaybemodifiedorrescindedbythestudent.Therecipientofthestudent’sinformation

(asname

donlinesabove)agreethattheyshallnotdisclosethespecifiedinformationtothirdparties

withouttheexpressconsent/authorizationofthestudent.

INFORMATIONTOBERELEASED:

ThefollowinginformationfrommyrecordsatAlbanyStateUniversitymaybedisclosedtotheabove

specifiedperson(s):

____Schedules,GradesandAcademicS

tanding

____DisciplinaryRecords

____TuitionandFeeStatements

____FinancialAidInformation

____Allrecordsorinformationpertainingtostudent

____Other,pleasespecify(_____________________________________________________________)

IhavereadandunderstandthecontentsofthisconsentformpertainingtotheFamilyEducational

RightsandPrivacyActof1974.

Student’sSignature:

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

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FERPA-Authorization - FERPA Authorization

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