FERPA Consent to&Release Educational Records
The Fam ily Education$Rights and Privacy Act of 1974 (FERPA) states that a student m ust authorize in$writing$the
release of$her$or$his educ atio na l records to a third pa rty.$ Please print legibly in$ink w hen$completing this form.
Student Nam e: ________________________________________________________________________
Student ID: ___________________________________________Date of Birth: _____________________
Person(s) to whom you authorize&the release of your records: ___ ___ __ __ ___ __ __ __ _______________
You can list multiple people.&You&must provide each&authorized&person listed with the&password you choose&below. If they are
unable to$provide the password,$your records cannot$be released.
You are responsible for the security of this password. Protect it from unauthorized&parties.
I authorize&the&release&of educational records in the following areas (check all
Select the&duration for&w h ich you authorize th e release&of you r educational records. Granting access to the
parties listed$does not preclude you$from revoking$access to$any of the parties or record$types above,$if done so in writing.
Grant continuous access for the duration&of my academic career.
I do not wish to grant continuous access. Access should end on _____/_____/_____.
I realize that if I choose to limit access no information will&be shared with the people listed above after
the date I select. Access can only be reinstated by completing a subsequent&FERPA Consent to Release
Educational Records form.
Student Signature: ______________________________________________ Date: _________________
Form must be&submitted in person at the office below, along with a picture ID. Otherwise a Notary signature is required.
I am not sub mitting my form in p e rs o n . My notary verific a tio n is b e lo w .
Notary: _______________________________________________ Commission Exp: _________________
Southwest Virginia Community College
PO Box SVCC
Richlands, VA 24641
Office Use Only
Person who ent
ered authorization into SIS: ____________________________________________&Date entered: ________________________
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