3/7/2019 BMM
Davidson County Community College
FERPA CONSENT FORM
(Family Educational Rights and Privacy Act)
STUDENT INFORMATION Student ID:
First Name:
Last Name:
Date of Birth:
Phone:
CONSENT TO DISCLOSE PERSONALLY IDENTIFIABLE INFORMATION
I hereby consent to the disclosure of education records maintained by DCCC (listed below).
The following individuals or agencies may have access to these records for the purpose of
providing assistance in reaching my goals.
Full Name Relationship Phone Email
I understand that (1) I have the right not to consent to the release of my education records,
(2) I have the right to inspect records disclosed upon request, (3) and that this consent shall
remain in effect until revoked by me and delivered to the DCCC Registrar, but that any such
revocation shall not affect disclosures previously made by DCCC prior to the receipt of any
such written revocation.
Consented and agreed to:
Student Signature Date
EDUCATION RECORDS ALLOWED (check one or more to grant authorization)
□ Academic – Grades/GPA, demographic, registration, student ID number, academic
progress status, and/or enrollment information
□ Financial – Billing statements, charges, credits, payments, past due amounts, and/or
collection activity
□ Financial Aid – Awards, application data, disbursements, eligibility, and/or financial aid
satisfactory academic progress
*********************************************************************
REVOCATION OF CONSENT (not valid until received by the Registrar)
I hereby revoke the consent granted to the individuals or agencies above.
Student Signature Date
