I,
Caldwell Community College and Technical Institute
Student Consent for Release of
Non-Directory Information
FERPA (Family Educational Rights and Privacy Act) is a federal statute that precludes Caldwell
Community College and Technical Institute from providing student record information to anyone but the
student without the student’s written authorization
By completing this form, you are authorizing Caldwell Community College and Technical Institute to
release information regarding your student record(s) to the individuals listed below. This includes (but is
not limited to) information related to financial aid, billing, attendance, grades, advising, etc. I understand
the individuals below must provide my student ID# and birthdate in order to conduct any College
business on my behalf, and it is my responsibility to provide this information to them. This release
replaces all previous authorizations and is in effect from the date signed until I submit a request revising
or revoking the release of information.
Proof of an unexpired government ID will be required from you when submitting this form. Proof of an
unexpired government ID will also be required from the individual(s) to whom access has been granted
when requesting information about you.
I ___________________________________ grant permission to Caldwell Community College and
Student’s Name (Please Print)
Technical Institute to release non-directory information to: (list individuals below)
Name of Individual:
Relationship:
This permission remains in effect until I cancel by notifying the Student Services Office in writing.
Check only if you currently have a Consent for Release of Non-Directory Information on file.
the undersigned, do rescind prior authorization given to the third parties for release of information.
Signature of Student Services Office Witness
Revised 4/25/18
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