Enrollment Management
Records and Registration
One University Drive
Camarillo, CA 93012
Phone: (805) 437-8500
FERPA Consent to Release
Student Academic Information
To (name of University Official/Department):
Please provide information from educational records of (print student name):
Student's Signature Date
To (print name of person, or persons):
Administrative Use Only- Records & Registration
Processed by: ________ Student Notification: _________
(Staff Initials) (Date)
G:\AR\30 - RECORDS & REGISTRATION\02 Documentation_How to Guides_Training Materials\Forms\Student Forms
Revised 01/23/2014
The only type of information that is to be released under this consent is:
Please note: This consent does not cover medical records.
Family communication
Employment
Educational Records* (Please specify):
Enrollment Verification (Request is a separate form)
Official CSU Channel Islands Transcript (Request is a separate form)
Admission to another educational institution
Other (Specify):
*An Educational Record is anything that directly relates to a student and is maintained by the University
The information is to be released for the following purpose,or purposes:
I understand the information may be released orally or in the form of copies of written records, as preferred by the
requestor. Authorization to review educational records will expire 30 days from the last day of classes for the term
indicated above. Access may be renewed by filling out a new form each term.
Student ID Number
For the
Fall/Spring
semester,
Year
This person is my (print relationship to student):
