SIMMONS UNIVERSITY
Office of the Registrar
300 The Fenway, Boston, MA 02115
Tel 617.521.2111 Fax 617.521.3144
Information Release Form
Current Name:
Name During Attendance:
Simmons ID #:
Approximate Dates of Attendance:
Degree Earned (if applicable):
Date of Birth: / / Daytime Phone:
E-mail Address:
GENERAL INFORMATION
FERPA is a federal law that governs and protects your rights to your individual educational
records. As a student over the age of 18 years or enrolled in a post-secondary institution, your
primary rights under FERPA are:
The right to review and inspect your educational records;
The rights to have your educational records amended or corrected;
The rights to control disclosure of certain portions of your educational records.
You can find more information about FERPA on the U.S. Department of Education’s website at
http://www.ed.gov/policy/gen/guid/fpco/ferpa/index.html
PERMISSION TO RELEASE
I hereby give the Registrar’s Office at Simmons University permission to release my
information to the third party listed below. I will hold Simmons University free of liability for
the exchange of this information and any other reasonable and necessary information to the
employment process.
Name of Third Party: __________________________________
Address: ____________________________________________
Phone:
Fax:
Email:
My signature below indicates that I have read and understand this agreement.
Signature:
Date:
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome