Fillable Form must be completed in pen. All fields (Florida Polytechnic University)

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Form must be completed in pen. All fields (Florida Polytechnic University)

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University Registrar’s Office
(863) 874-8540
registrar@floridapoly.edu
8AM-5PM, M-F IST 2052
Limited Release of Educational Records Request
Form must be completed in pen. All fields are required; incomplete forms will not be processed. Student must sign and
present this form to the Registrar’s Office with a valid photo ID to verify Authenticity of this release. This limited release
will supersede any FERPA blocks the student may have requested for their Educational Records for the individual listed
below during the designated period of time.
Visit, https://floridapoly.edu/registrar/ferpa.php for more information.
________________________________________________ _______________________________________
Student’s Last Name, First Name Student UID
________________________________________________ _______________________________________
Email Address Phone Number
Third-Party Designee Information
________________________________________________ _______________________________________
Last Name, First Name Organization/School/Relation to Student
_______________________________________________________________________________________________
Address City State Zip
The authorized third-party designee listed above will be asked for the following passphrase to authenticate their identity.
Passphrase:
There is a 30 character limit. Foul language, crude references, or inappropriate phrases will not be accepted.
Educational Records information to be released (Be specific):
________________________________________________________________________________________________
Purpose of release (Required):
________________________________________________________________________________________________
I give permission for ____________________________ to release the specified information to the recipient listed above.
Florida Poly Staff/Instructor Name
Release expires one month after student signature date or on _________________________ (not to exceed one year).
Month/Day/Year
_______________________________________________________ _______________________
Student Signature Date
UNIVERSITY REGISTRAR’S OFFICE ONLY
Photo ID Verified By: __________________________ Date: ______________________________
Processed By: ________________________________ Date: ______________________________
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Form must be completed in pen. All fields (Florida Polytechnic University)

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Completed 15 August 2020

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