Fillable FERPA Authorization To Release Information From Student Education Records Ccs 40-200 (Spokane Community College)

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FERPA Authorization To Release Information From Student Education Records Ccs 40-200 (Spokane Community College)

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CCS 40-200 (Rev. 04/19)
Marketing and Public Relations
FERPA AUTHORIZATION TO RELEASE INFORMATION
FROM STUDENT EDUCATION RECORDS
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, can be released without the prior consent of the student. All sections must be completed
for release to be valid.
Location:
Spokane Community College
Spokane Falls Community College
REQUESTED BY (STUDENT):
First
M.I.
Birthdate (mm/dd/yyyy)
SSN Optional*
SID (EMPLID) Required*
Information to be Released or Revoked
Duration of this Authorization
Complete access to all records with no exceptions
Until Date
/ /
Academic records
Until I graduate or am no longer enrolled/leave
CCS
Financial Aid, grants or scholarships records
Billing records
Until I revoke FERPA Authorization
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 (format of xxx-xxx-xxxx):
Phone Number (format of xxx-xxx-xxxx):
Relationship to student:
Relationship to student:
The Community Colleges of Spokane assumes no responsibility for the confidentiality of records transmitted by fax, e-
mail or other delivery methods for which identification of the recipient cannot be personally verified by a college official.
By signing this form, I authorize Community Colleges of Spokane (CCS) to release and disclose information from my
educational records as specified for the period of time indicated. This authorization remains in effect as specified or
until I revoke this authorization in writing to the appropriate CCS Registrar’s Office.
Student’s Signature
Date
/ /
Send original completed form to:
SCC Bigfoot Central (MS 2151) Building 15
Fax #: 509-533-8181
Email: registrationoffice@scc.spokane.edu
SFCC Registrar’s Office (MS 3011) Building 17
Fax #: 509-533-3237
Email: sfcc.admissions@sfcc.spokane.edu
If sending by fax, email or mail, you must include copy of photo ID with signature for release to be valid.
Reset Form
CCS 40-200 (Rev. 04/19)
Marketing and Public Relations
FOR OFFICE USE
Disclosure Information
Requested by the student in person and ID checked
Requested by the student via Mail Fax US Mail and copy of ID with signature included
Form completed, signed and dated
Recorded in ctcLink on
/ /
By Staff
Date
Scanned in halFile on
/ /
Date
Send form to appropriate institution for processing
Copy to Financial Aid
Copy to other: ____________________________
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FERPA Authorization To Release Information From Student Education Records Ccs 40-200 (Spokane Community College)

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Completed 27 July 2020

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