North Carolina A&T State University
Student Release Authorization Form
In compliance with Federal Family Education Rights and Privacy Act of 1974 (FERPA), North Carolina A&T State University
(NC A&T) is prohibited from providing certain information from your student records to a third party, such as grades, billing,
tuition and fee assessments, financial aid (including scholarships, grants, work-study or loan amounts) and other student record
information. This restriction includes, but is not limited to, your parents, spouse or a sponsor. FERPA is a Federal law that
protects the privacy of student education records. In order for the University to release information to anyone other than yourself,
various on-campus offices, federal, state and law enforcement agencies are exempt under the FERPA law, this release form must be
signed by you (the student) and will remain in effect until revoked by you in writing.
Please note that it is the policy of NC A&T not to release certain aspects of student records (income, grade point average, grades,
and account balance) over the telephone or via e-mail. Students must visit the respective offices to obtain this information.
I hereby waive my rights under FERPA and authorize NC A&T the right to release or discuss my student information with
University staff/faculty in the Admissions; Registrar; Financial Aid; Treasurer’s Office; New Student Programs; Housing &
Residence Life; Student Affairs; Athletic Department; Distance Learning and other University offices. In addition, I authorize NC
A&T to release or discuss my student information and other non-directory information to the parties (parent(s), spouse, employer,
high school, scholarship provider and other agencies) listed below:
(Please Print; Information will not be released if we cannot read the individual or organization’s name.)
SECTION A. Student Information
Student Name (Last, First, Middle Initial):
_____________________________________________________
Telephone Number ( ) __________________________ Cell or Home
Email Address:
@ncat.edu
Banner ID:
950____________
Designate a 4 Digit Passcode
____________
(The Passcode must be provided
to the individual/agencies listed
below.)
SECTION B. Third Party Designee
Name (Last, First, Middle Initial or Agency/Organization Name):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Relation to Student
__________________
__________________
__________________
__________________
Daytime Telephone Number
( ) _________________
( ) _________________
( ) _________________
( ) _________________
SECTION C. Certification
I understand that by signing this authorization:
I authorize the above third party, named in Section B, access to my educational information.
I understand University policy prohibits the release of certain aspects of student records over the telephone, as indicated
above.
I attest that I am the student signing this form.
I understand that this authorization will remain in effect until I submit a written request to cancel it.
Student’s Signature
Date
************************************OFFICE USE ONLY************************************
Received By: ___________________________________ Date Received: _______________
Processed By: ___________________________________ Dated Processed: _______________
Retu
rn this form to: Office of the Registrar, 1601 East Market Street, Greensboro NC 27411
RELEAS
R
EVISED 03/11
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome