The Family Educational Rights and Privacy Act (FERPA) is a Federal law designed to protect the privacy of a student's education records, including academic,
financial and financial aid records. The law applies to all schools that receive funds under a program of the U.S. Department of Education. This act protects
your personal information from being distributed to third parties without your consent, unless permitted by law. This form must be completed and returned to
the appropriate University office either by fax or mail, before any information can be released to a third party (i.e., spouse, employer, etc.). This form remains
on file with the University.
WALDEN UNIVERSITY Student Information Release Form (FERPA)
STUDENT INFORMATION:
Social Security Number
Home Phone NumberWork Phone Number
Student's Name (Last, First, Middle Initial)
Street Address
City State ZIP
Email Address
Date of Birth (Format: YYYY-MM-DD) [Note: Third Party must give student's date of birth to verify identity when requesting information.]
REASON FOR RELEASE:
Full Name and/or Title of Individual Company Name
Work Phone Number Home Phone Number
RELEASE INFORMATION TO:
Street Address
City State ZIP
Student Signature Date
I hereby authorize release of the data specified above to the individual named above, for a period of one year from date of receipt
.
SPECIFIC INFORMATION TO BE RELEASED:
Email Address
RELEASE AUTHORIZATION:
Office of the Registrar
650 S. Exeter Street
Baltimore, MD 21202
Fax: 410-843-6416
Office of Financial Aid
Office of the Bursar
650 S. Exeter Street
Baltimore, MD 21202
Fax: 410-209-8029
Select one of the options below to identify the type of information to be released. Return this form to the corresponding office.
Academic Record Financial Aid Information Information Relating to My Student Account
7070 Samuel Morse Drive, Suite 250
Columbia, MD 21046
Fax: 410-209-8026
click to sign
signature
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