Fillable FERPA CONSENT TO RELEASE STUDENT INFORMATION (California State University, Dominguez Hills)

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FERPA CONSENT TO RELEASE STUDENT INFORMATION (California State University, Dominguez Hills)

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FOR OFFICE USE ONLY
PLACE DATE STAMP HERE
FERPA CONSENT TO RELEASE
STUDENT INFORMATION
OFFICE OF ADMISSIONS AND RECORDS (WH 290)
Last Updated: March 23, 2020
STUDENT ID:
PHONE NUMBER:
LAST NAME:
FIRST NAME:
ADDRESS:
CITY:
STATE:
ZIP CODE:
THIS FORM MAY ONLY BE SUBMITTED IN PERSON BY THE STUDENT
Please provide information from my educational records to the following persons:
Last Name
First Name
The only type of information that is to be released under this consent is:
(Please Indicate All Applicable Records)
All Records □
Disciplinary Records □
Financial Aid □
Transcripts □
Recommendations for Employment or Admission to Other Schools □
Student Financial Services □
University Advisement Center (Academic Advising) □
Other (please specify below) □
______________________________________________________________________________________
The information is to be released for the following purpose(s):
(Please Indicate All Applicable Records)
Admission to an Educational Institution □
Employment □
Family Communications about University Experience □
Other (please specify below) □
______________________________________________________________________________________
I understand the information may be released orally or in the form of copies of written records, as
preferred by the requester. I have a right to inspect any written records released pursuant to this
Consent (except for parents’ financial records and certain letters of recommendation for which the
student waived inspection rights). I understand I may revoke this consent prospectively.
This consent does not cover medical records held solely by Student Health Services or the Counseling Center. Contact those offices for
consent forms.
_________________________________________ _________________
Student Signature Date
click to sign
signature
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THIS FORM MAY ONLY BE SUBMITTED BY THE STUDENT
Instructions: This request becomes effective beginning the semester it is submitted through the end of students' academic
tenure at the university. Students who wish this request to be withdrawn must update their FERPA restrictions online. Before
signing this form, you should carefully read the following:
This form will prevent the Office of Admissions and Records from verifying any directory information regarding your record to
anyone, including yourself, over the telephone or in writing without your signed, written consent. This form will prevent
verification for purposes of employment, loans, credit card applications and insurance. Always bring picture identification with
you for in-person inquiries. We will not release information without positive identification. Students who obtain a campus e-mail
account should be aware that name, student status and e-mail addresses cannot be withheld from Internet access.
If, after having considered this information, you would like to request that directory information be with-held, please sign and
date the form below and return this completed form to:
Office of Admissions and Records
Attention Records & Registration Unit
CSU Dominguez Hills
1000 E. Victoria Street
Carson, California 90747
FERPA Frequently Asked Questions
Where do I find CSUDH FERPA Policy?
https://www.csudh.edu/records-registration/records/ferpa/
How do I select or release FERPA restrictions?
Student may update FERPA restrictions by logging into their myCSUDH account. On the Student Center page, students should navigate to the Personal
Information section. Using the drop down dialog box, students may select Privacy Settings to update FERPA restrictions.
Who is protected under FERPA?
FERPA applies to the education records of persons who are, or have been, in attendance in postsecondary institution, including students in cooperative and
correspondence study programs and in any non-traditional delivery process, such as distance learning.
What are a student's rights under FERPA?
Under FERPA the student has the right to:
1. inspect and review their education records,
2. request to amend their education records,
3. to limit disclosure of personally identifiable information (information that would directly identify the student or make the student’s identity easily
traceable) known as directory information,
4. file a complaint with the Department of Education concerning an alleged failure by the institution to comply with FERPA.
What is an education record?
Education records are defined as records that are:
1. Directly related to a student, and
2. Maintained by an educational agency or institutions or a party acting for the agency or institution, if certain conditions are met.
What is not an education record?
Education records are not:
1. sole possession records,
2. law enforcement unit records,
3. employment records,
4. medical records, or
5. post attendance records.
What is "directory information"?
CSUDH considers the following “Directory Information”:
1. student’s name;
2. student’s address, including email and postal address;
3. telephone listing;
4. major field of study;
5. participation in officially recognized activities and sports;
6. weight and height of members of athletic teams;
7. dates of attendance;
8. degrees and awards received; and
9. the most recent previous educational agency or institution attended by the student.
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FERPA CONSENT TO RELEASE STUDENT INFORMATION (California State University, Dominguez Hills)

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Completed 18 August 2020

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