Revised 12/2018
Authorization for Release of Personal Information
(FERPA Policy)
Submit completed form to:
admissions@nwscc.edu
The Family Educational Rights and Privacy Act (FERPA) is a Federal law that protects the privacy of student educational
records. By signing this form, the student allows Northwest-Shoals Community College (NW-SCC) to release records to
parents, grandparents, spouse, and/or guardians, and other specified individuals.
I, ________________________________________________, hereby authorize NW-SCC to release the following records:
(PRINT NAME)
___ Financial Aid Records (records include: status of file, award and disbursement of funds information,
Satisfactory Academic Progress status, income information, and any other information contained in the
application of financial aid record).
___ Admission/Transcript Records (records include: transcripts, admission and registration information,
schedule information, and any other information contained in the academic records).
___ Student Account Records (records include: amounts due for tuition and fees; sources of payment for tuition
and fees; refund information; records hold information as it relates to parking tickets, library fines, and financial
aid repayments; and any other accounts receivable information contained in the student account records).
Please Note: Services for Students with Disabilities records are considered medical records and are not covered under the FERPA rules. A separate
release form must be obtained from disability services.
VENDOR CLAUSE: This form gives NW-SCC the authority to discuss all relevant matters with external vendors that will facilitate a service on behalf of the
student who is enrolled in an authorized college program (i.e., Student Success).
The following individual(s) are authorized to access the information indicated above:
Spouse __________________________________ Mother/Stepmother ___________________________
Father/Stepfather _________________________ Other _______________________________________
REQUIRED - Please select a 4-digit code that will be assigned to your record. In order for authorized individuals to
access your information, they will need to provide this code to the appropriate office: _____ _____ _____ _____
Although I understand I am not required to release this information, I am giving my consent to NW-SCC to disclose
these records. I also understand that this release remains in effect while I am a student at NW-SCC, unless I revoke my
consent in writing and deliver it to the Admissions Office at NW-SCC.
___________________________________ ________________________________ ___________
Student’s Signature Student Number or Social Security Number Date
FOR ADMISSIONS PERSONNEL ONLY:
Entered in Checklist _____
Processed by: _______________________________ ______________________
Signature Date
click to sign
signature
click to edit
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