Fillable FERPA Information and Waiver (Connors State College)

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FERPA Information and Waiver (Connors State College)

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FERPA Information and Waiver
Student Name:
Student ID Number:
The Family Educational Rights and Privacy Act (FERPA) of 1974 (the Buckley Amendment) insures
students of the right to privacy and confidentiality with respect to their educational records. With a student’s
written consent, the Registrar (or designee) may disclose any confidential information on file to any
individual or agency named by the student.
This form is provided as a means for students to give the Registrar (or designee) permission to discuss their
academic records with someone other than themselves (i.e., with a parent, guardian, etc.).
Written consent will be kept permanently on file. The Office of the Registrar (or designee) will release
information regarding the student’s educational record to those person(s) who have been designated on this
form. If for any reason a student decides to cancel this release, he/she must submit a letter
withdrawing the consent, indicate the person(s) affected, and send or deliver the written notice to:
Office of the Registrar, Connors State College, 700 College Road, Warner, OK 74469.
Please select one:
I do not wish to grant access to my education records to any individuals or agencies.
Please allow the listed individuals or agencies access to my records.
Understanding my privacy rights under FERPA, I consent to grant access to my educational records
to the individuals or agencies listed below:
Name:
Relationship:
Name:
Relationship:
Password:
(Student is responsible for notifying
the above with the password.)
I understand that this release allows the individuals above to discuss my educational records with college
officials or to schedule an appointment to view my educational records in person. This release does NOT permit
the individuals below to request official documents, make changes to my records, or otherwise conduct
educational business on my behalf (i.e. order transcripts, drop/add classes). College officials may discuss details
of all educational records with the individuals listed below, including grades, class schedule, academic standing
(probation, etc.), disciplinary records and bursar information. It excludes sharing information from police or college
medical records. This release is in effect until I revoke it in writing. Educational Records consist of grades,
transfer information, academic transcripts, and related records of academic standing.
Student’s
Signature:
Date:
Received
By:
Date:
Last updated 7/8/2019
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FERPA Information and Waiver (Connors State College)

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Completed 29 January 2021

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