Authorization to Release Information
This form serves as student consent for records to be released to Parent(s), Legal Guardian(s), Other
tuition providers or other indicated individuals:
Student’s Name: RAM ID:
___________________________________________ _______________________________________
PLEASE READ:
In accordance with the Family Educational Rights and Privacy Act of 1974 (FERPA), the undersigned
student hereby permits Albany State University to disclose the information specified below to the
following individual(s) or agency(ies):
Name: ________________________________________________________________
Name: ________________________________________________________________
Name: ________________________________________________________________
Name: ________________________________________________________________
This consent shall be valid throughout the student’s enrollment at Albany State University and thereafter,
but it may be modified or rescinded by the student. The recipient of the student’s information (as named
on lines above) agree that they shall not disclose the specified information to third parties without the
express consent/authorization of the student.
INFORMATION TO BE RELEASED:
The following information from my records at Albany State University may be disclosed to the above
specified person(s):
Schedules, Grades, and Academic Standing
Disciplinary Records
Tuition and Fee Statements
Financial Aid Information
All records or information pertaining to student
Other, please specify: ________________________________________________________________
I have read and understand the contents of this consent form pertaining to the Family Educational Rights
and Privacy Act of 1974.
Student’s Signature: Date:
_____________________________________________________ __________________________
Please return your completed form to
the Office of Academic Advising and
Retention in BCB 292 or via email at
Elizabeth.Sheffield@asurams.edu
