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Student Name: _____________________________
Student ID #: _____________________________
It is the policy of Alamance Community College, in accordance with the Family Educational Rights and Privacy Act
(FERPA), to withhold personally identifiable information contained in our students’ educational records unless the
student has consented to disclosure or FERPA allows disclosure. Directory information, such as enrollment, academic
honors and degrees, may be disclosed to the public. However, private information, such as address, phone number,
grades, class schedules, the student’s account, and financial aid awards may not be released without express consent
from the student.
Signing this form provides such consent, according to the information designated for release and to whom it is to be
released.
I, ______________________________________, Student ID Number_______________, authorize Alamance
Community College to release the following educational records, upon request, to the persons listed below, for the
purpose of keeping them informed regarding my education at Alamance Community College.
Please select all that apply:
_____ All academic records. _____ All contact information
_____ All Financial Aid Information.
_____ All Student Conduct/Disciplinary Records
_____ Other___________________________________________________________
Persons to whom information may be released:
Name: ___________________________________________________
Name: ___________________________________________________
Name: ___________________________________________________
Note that student must appear in person at Alamance Community College Admissions Office to verify his/her identify
by presenting a valid government issued photo identification (ID), such as, but not limited to, a driver’s license, other
state issued ID, or passport. If the student cannot appear in person then this form either needs to be verified by an
appropriate school official or notarized by a Notary Public (See page 2) and then sent to Alamance Community
College. Once signature is verified or notarized return completed form to: Alamance Community College, Attn:
Student Success, P.O. Box 8000, Graham, NC, 27253.
I acknowledge by my signature that I understand that, although I am not required to release my records, I am giving my
consent to release the designated information to the above named person(s). I understand that this release will remain
in effect until revoked in writing (& received and processed by Alamance Community College) and must be renewed
annually each school year.
Signature: _____________________________________________ Date: ________________________
Verified by (Name/Signature): ____________________________________________ Position: ______________ Date: ____________
Processed by: _________________________________________ Date: ________________________
