FERPA Student Authorization to Release Education Records
Student’s Name: __________________________________________________________
SHU Student ID Number: _______________________________________
FERPA Notice
The Family Educational Rights and Privacy Act of 1974 (FERPA), initially called the Buckley
Amendment, allows students at an institution of higher education to control outside access to
their education records, including request for information from their parent, guardians, or
others as designated by the student. Submitting this completed form allows the Sacred Heart
University to disclose information from a student’s education records to outside third parties.
Release Information to:
Name(s): ______________________________________________________________________
Relationship: __________________________________________________________________
Street Address: _________________________________________________________________
City: _____________________________________ State: ______________ Zip: _____________
Phone: _______________________________________________________________________
Email: ________________________________________________________________________
Please release the following records (check all that apply):
□ Enrollment Status □ Course Schedule □ Grades
□ Academic Transcript □ Graduation Date □ Degree Status
I hereby authorize Sacred Heart University to release confidential information about me contain
in the University’s records. I agree to hold Sacred Heart University and its employees harmless
for any unauthorized use of my student records obtained by the above name party.
Student Signature: ___________________________________________ Date: _____________
click to sign
signature
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