Permission to Release Education Records Maintained by a College/School to a Third Party
I. Instructions for Student
1. Fill out this form. Sign and date the form.
2. Return the completed form to your college/school office.
3. This release will be in effect until you cancel it in writing, or for the duration of your studies in the specified college/school, whichever comes
first.
4. To rescind the access, contact your college/school office in person and complete Section V of this form, or send a letter to your
college/school office, indicating cancellation of the access.
5. To change the access you wish to grant, rescind the current access and fill out another form for the new access.
II. Instructions for College/School
1. Maintain this form in the student's file.
2. Before you discuss a student's record with anyone who does not have an educational need to know, you must first verify that the student has
allowed this access to his/her information in the 'Third Party Information' section of this form
3. Maintain a record in the student's file each time a release is made, to include: the information released, who released the information and to
whom the information was released.
4. Maintain all forms and any letters the student has sent granting and/or rescinding access in the student's file.
Name
Last
First
Middle
College/School
Email Daytime Phone:
@marquette.edu
Signature of Student:
Date
IV. Third Party Information - Name(s) of Person(s) with whom the college/school may discuss my record:
Rev. 12/2009
Major
MUID
( )
I hereby authorize and grant permission to any administrator/faculty in my college/school to provide unofficial copies of, and/or discuss any and all records related
to my education at Marquette, that are maintained by the college/school, including, but not limited to the academic and disciplinary records to the person(s) listed
below. I understand that even if I have placed a FERPA Address, Email Address or Phone Number block on my record, I am granting permission for the
college/school to release this information to the person(s) indicated below. Furthermore, I confirm my understanding that, even if I have placed a
Complete FERPA Name Block on my record, I am granting permission for the college/school to release the information described above to the
person(s) indicated below. Finally, I understand this permission will be in effect for the duration of my studies in the college/school indicated above, or until I
notify the college/school in writing of my desire to rescind this permission.
Middle
First
Last
1. Name
Middle
First
Last
2. Name
Relationship to student:
Signature of Student:
Date
Relationship to student:
V. Rescind Permission (use this section only when you no longer wish to grant access to the people listed above):
I hereby rescind the above permission for my college/school to discuss the information contained in my academic record with any person who does not have an
educational need to know.
II. Student Information:
