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FERPA Consent to Release
Educational Records
TIDEWATER
COMMUNITY COLLEGE
From here, go anywhere.
TM
The Family Education Rights and Privacy Act of 1974 (FERPA) states that a student must authorize in writing the release
of her or his educational records to a third party. Please print legibly in ink when completing this form.
Student Name: __________________________________________________ Phone:_______________________________
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.
Password: ____________________________________________________________________________________________
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 that apply):
q Academic Records
q Financial Aid
q Student Accounts
q Veterans Affairs
Select the duration for which you authorize the release of your 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.
q Grant continuous access for my academic career.
Start Date _______/_______/_______ End Date _______/_______/_______.
Month Day Year Month Day Year
q I do not wish to grant continuous access. Access should end on _______/_______/_______.
Month Day Year
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 submitting my form in person. My notary verification is below.
Notary: __________________________________________________ Commission Exp: _____________________________
Form Received By: ___________________________________________________________ Date: ____________________
Return Completed Form to Enrollment Services:
Chesapeake Campus Norfolk Campus Portsmouth Campus Virginia Beach Campus
Pass Building, Rm. 175 Andrews Building A Building Bayside Building
1428 Cedar Road 300 Granby Street 120 Campus Drive 1700 College Crescent
Chesapeake VA, 23322 Norfolk VA, 23510 Portsmouth VA, 23701 Virginia Beach VA, 23453
Office Use Only
Person who entered authorization into SIS: __________________________________ Date entered: _________________
WC 9/11/17
11/2016
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