Saint Leo University provides for the confidentiality of student records in accordance with the Family
Educational Rights and Privacy Act (FERPA), as amended. Accordingly, in order for us to be able to
discuss your education record with your parents, spouse, or other persons who you designate, you must
provide your authorization.Education record” includes those records, files, documents and other
material that contain information directly related to the student and are maintained by the university or
a person acting for the university. This includes admission, enrollment, financial aid, academic, and
disciplinary records. An education record includes information recorded in any medium but does not
include personal notes, records only available to law enforcement personnel,
employment records, or
medical records.
Name of Student ___________________________________________________________________
SLU ID Number __________________ Last 4 of SSN ______________ DOB ________________
In accordance with the Family Educational Rights and Privacy Act (FERPA), I authorize Saint Leo
University to release my education record to the following persons, agencies, or organizations for
keeping such persons, agencies, or organizations informed of my progress at Saint Leo University:
Name(s) ___________________________________________________________________________
Relationship ________________________________________________________________________
Agency/Organization _________________________________________________________________
Address ____________________________________________________________________________
Phone Number ______________________________________________________________________
I understand that by signing this authorization, I am waiving my rights of nondisclosure of these records
under federal law only to the persons or entities specifically listed. This release does not permit the
disclosure of these records to any other persons or entities without my written consent or as permitted
by law. This consent will remain in effect until revoked by me, in writing, and delivered to the Registrar’s
Office of Saint Leo University, but that any such revocation shall not affect disclosures previously made
by SLU prior to receipt of any such written revocation.
Return this form to: Saint Leo University, Registrar’s Office, MC - 2278, P.O. Box 6665, Saint Leo, Florida
33574. Fax Number: 352-588-8656.
_________________________________________________ Date _________________
Student’s Signature