Fillable FERPA Release FERPA Release-MultiOffice v2

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FERPA Release FERPA Release-MultiOffice v2

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LOCKHAVENUNIVERSITY

AUTHORIZATIONFORRELEASEOFINFORMATION

TheFamilyEducationalRightsandPrivacyActisafederallawdesignedtoprotecttheprivacyofastudent’seducationalrecords.Educationalrecordsare

allrecordsthatcontaininformationdirectlyrelatedtoastudentandaremaintainedbyaneducationalagencyorinstitutionorbyapartyactingforthe

agency

orinstitution.AllFERPArightstransferfromtheparenttothestudentwhenastudentattendsapostsecondaryinstitution.Thestudent

maintainstherightstohis/herrecordregardlessofparentalinformationthatmayhavebeenrequiredwhenastudentappliedforfinancialaidorifthe

parentpaysthestudent’sbill.Therefore,LockHavenUniversityemployeesareunabletodiscussmatterswithmembersofthestudent’sfamilyorother

personswithouttheexpresswrittenconsentfromthestudent.Thestudentwillcompletethisformandreturnittotheaddressorfaxnumberbelow.



InaccordancewiththeFamilyEducationalRightsandPrivacyAct,Iauthorizethereleaseofinformationindicatedbelowtothedesignatedindividuals.



_________________________________________________________________________________________

Student’sName(Print)  Student’sLHUID



_____________________________________________________________________________________________________________

Student’sSignatureDate



_____________________________________________________________________________________________________________

Student’sDateofBirthStudent’sLast4DigitsofSocialSecurityNumber



RELEASEISGRANTEDTOTHEFOLLOWINGINDIVIDUAL(S)

LegalNameofIndividual(s)to

Hear/ReceiveInformation

Relationshipto

Student

Last4DigitsofSocial

SecurityNumber

DateofBirth

(Month/Day/Year)

RecordstobeReleased



___Academicrecords*

____Billingrecords

____Financialaidrecords

____Studentdisciplinaryrecords



___Academicrecords*

____Billingrecords

____Financialaidrecord

____Studentdisciplinaryrecords



___Academicrecords*

____Billingrecords

____Financialaidrecord

____Studentdisciplinaryrecords



___Academicrecords*

____Billingrecords

____Financialaidrecord

____Studentdisciplinaryrecords

*TheRegistrar’sOfficewillnotreleasegradesorgradepointaverageoverthephonetothestudentortoindividualsidentifiedabove.Asignedtranscript

requestformmustbesubmittedtoobtainthisinformation.



Whenthedesignatedpersoncalls,he/shewillbeaskedtoprovidetheanswertoasecurityquestion.Pleaseselectonequestionandprovideananswer.

Besurethatyouinformthepeoplelistedaboveofyourquestionandanswer.Foryourprotection,noinformationwillbesharediftheansweris

incorrect.



Question(chooseonlyone) Answer

_____Whatismymother’smaidenname?

_____Whatisthenameofmypet?

_____Whoismyfavoriteentertainer?

_____Whatismyfather’smiddlename?



Returncompletedformto:

LockHavenUniversity–FinancialAidOffice‐‐UlmerHall224(Fax:570‐484‐2918)



Thisauthorizationremainsineffectfortheentiretimeofthestudent’senrollmentatLockHavenUniversityunlessrescindedinwritingbythestudent

oruponwithdrawal/graduation,whichevercomesfirst.



Copiesdistributed:___Registrar___Residence&StudentLife



I:\FERPA\FERPARelease‐MultiOfficev2.docx‐updated06/09/2016(Registrar’sOffice)

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FERPA Release FERPA Release-MultiOffice v2

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Completed 18 November 2019

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