FERPA Consent Form
NewburghCampus
1WashingtonCenter,Newburgh,NY12550
MiddletownCampus
115SouthStreet,Middletown,NY10940
(845)3414140●registrar@sunyorange.edu
Name of Student (Last, First, Middle Initial) Student ID#: A Date of Birth:
Address:
City: State: Zip:
Telephone Number:
Semester: Fall Spring Summer Winter Year: _________
Please complete the following only if you want another party to have access to your educational
records.
Consent to release confidential information from a student’s educational records without the student being
present. In compliance with the Family Educational Rights and Privacy Act (FERPA), the disclosure of
information from a student’s educational record is considered confidential and will not be released, with
certain exceptions, without the student’s written consent. In accordance with FERPA, SUNY Orange will
disclose to a parent(s), spouse, other family member(s), or third party(s) information from the student
education record provided the College has on a file written consent from the student.
Please complete the following information below and return in person to the Records and Registration Office
in Middletown or Student Services Central in Newburgh. You will be required to show picture ID in order for
the form to be officially accepted.
Please visit our website at http://www.sunyorange.edu/academic_services/ferpa.shtml for detailed information about FERPA
This form is only valid for one Academic year unless consent is withdrawn before the end of the Academic
year. A new form must be submitted every year. (If you start in the Fall semester you will have to submit a
new one the following Fall semester)
Name Relationship to Student Phone Number
Specific Records that may be disclosed (Check All That Apply)
Financial Aid Student Accounts Grades Attendance/Schedule
Special Accommodations Other (must specify)_____________________________________________
State the purpose for the disclosure (must be filled out):
Student Signature: Date:
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