Fillable FERPA RELEASE/CANCELLATION FORM (River Parishes Community College)

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FERPA RELEASE/CANCELLATION FORM (River Parishes Community College)

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UPDATED: June 11, 2019
FERPA RELEASE/CANCELLATION FORM
Purpose:
The Family Educational Rights and Privacy Act (FERPA) prohibits access to, or release of, education
information without the written consent of the student.
The consent must by in writing, signed and dated by
the student, and must specify records to be released, reason for release, and the names of the parties to
whom such records shall be released. The act applies to all persons formerly and currently enrolled at
an educational institution. Access to educational records does not give permission to make changes to
the student’s record.
The purpose of this form is to authorize RPCC to release or cancel prior authorized release of FERPA-
protected information to certain persons (Related Policy: Release of Student Information, found in the
2019-2020 Catalog)
Student’s Name: Lola Number: ______________
Email Address: _____________________________________ Phone Number: __________________
This authorization is valid until cancelled by the student. The student may cancel a release at any time by
completing another FERPA Release/Cancellation Form.
I hereby give permission for River Parishes Community College personnel to release selected items below to
the recipients listed for the purposes of __________________________________________________
□ All records
□ Accounting- includes tuition and fee balances, financial holds, mailing and billing address, payment plans,
accounting statements, collections information and debt information
□ Admission - Includes date of application, program selected, documents received, documents pending, date
of admission, admission status and conditions of admission
□ Registration- Includes current enrollment, dates of enrollment activity, enrollment status, residency status,
semesters attended and mailing address information
□ Academic Records- Includes courses taken, grades received, GPA, academic progress, honors, transfer
credit award and degrees awarded.
□ Financial Aid-Includes all general financial aid information.
UPDATED: June 11, 2019
(P= Parent G= Guardian S= Spouse O= Other)
□ Release to □ Cancel ________________________________ Relationship
First, Middle Initial, Last Name
□ Release to □ Cancel ________________________________ Relationship
First, Middle Initial, Last Name
□ Release to □ Cancel ________________________________ Relationship
First, Middle Initial, Last Name
□ Release to □ Cancel ________________________________ Relationship
First, Middle Initial, Last Name
I understand in executing this authorization I waive the right for such information to be privileged and that a
photocopy of this authorization shall be as valid as the original.
Student Signature: ___________________________________ Date: __________________________
Routing Instructions
Completed forms must be hand delivered by the student making the request to the Student Services Office at the
Gonzales, Reserve, or Westside Campus. In order for the form to be processed, an RPCC staff member must
verify that the person delivering the form is the student requesting the release/cancellation. A government-
authorized photo ID is required.
For Office Use Only:
D
ate Received: __________________ Photo ID Verified By: _________________________
T
his form must be given to the Registrar’s Office for processing.
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FERPA RELEASECANCELLATION FORM (River Parishes Community College)

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Completed 26 July 2020

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