800 Mickelson Drive
Rapid City, SD 57703-4018
605-718-2400 Fax: 605-394-2204
Toll Free: 1-800-544-8765
FERPA Revocation of
Reference Authorization
Student’s Name: ________________________________ Student ID#:_____________
The Family Educational Rights and Privacy Act of 1974 (FERPA) permits an individual to
revoke authorization to release information needed to provide references.
By signing this form, I am revoking the permission for the following person,
_______________________________, to provide an oral or written evaluation of any aspects of my
academic performance, including classroom and/or lab performance, attendance, and attitude, as well as
job-related criteria such as team work, productivity, and ability to work independently, or on my
education records at Western Dakota Tech, and to release information from my education records,
including grades, GPA, class rank, disciplinary actions, any information pertaining to my education at
other institutions I have previously attended which is part of my education records at WDT, and any other
personally identifiable information whether or not contained in my education records.
I understand this revocation shall not affect disclosures made by staff of Western Dakota Tech who
were authorized prior to the receipt of this revocation
Student’s Signature: ________________________________________________ Date: ______________
Received by: ________________________
Initials Date
FERPA Permissions Updated by: ________________________
Initials Date
Original: Registrar’s Office Copy: WDT Personnel Named Above Copy: Student