OFFICE OF RECORDS & REGISTRATION
_________________________________ _________________________
Student Name University Identification Number (UIN)
The Family Educational Rights and Privacy Act 1974 (FERPA), requires FGCU to treat non-directory information (i.e. Date of
Birth, Religion, Citizenship, Disciplinary Status, Ethnicity, Gender, GPA (Grade Point Average), Marital Status, UIN, and SS#) as
confidential information. Such information cannot be released to anyone other than the student. By FERPA definition, under
most conditions, parents, legal guardians and/or spouses are considered as third party individuals and are not allowed access
to education records without written consent of the student. Parents may also receive access to the student’s education
record through compliance with a subpoena, in connection with a health or safety issue, or by providing a copy of recent
federal income tax form noting the student as a dependent of the parent (Internal Revenue Code of 1986, Section 152).
I, the student, understand that by signing this form, I grant FGCU permission to discuss and/or release information
pertaining to my education record to the person(s) listed below. This information may be related to directory or non-
directory information. Directory Information includes name, university email address, mailing address, major field of study,
dates of attendance, enrollment status, class status, degrees and awards received, participation in officially registered
activities and sports and athletes’ height and weight). I also understand that Behavioral/Conduct Records and
Medical/Health information are not encompassed in this release.
NOTE: Until you decide to rescind your request, the University will continue to release such information, even after your
enrollment has terminated.
Unless specified below, this permission includes all areas deemed necessary by the University during my enrollment (i.e.
Registration Records, Financial Aid Records, and Business Office Records).
I understand this consent form will be in effect for the entire FGCU educational career, unless I notify the Office of Records
& Registration in writing.
NAME:
RELATION:
NAME:
RELATION:
NAME:
RELATION:
NAME:
RELATION:
Limitation of Information to be Released (Please check one)
The release of information is unlimited at the discretion of the University.
Please rescind my request for third party authorization for the person (s) listed above
The release of information includes anything EXCEPT for the following: ___________________________________
____________________________________________ _______________________________________
Student Signature Date
10501 FGCU Blvd. S.
Ft. Myers, FL 33965-6565
Local: 239-590-7980
Fax: 239-590-7983
ORR@fgcu.edu
AUTHORIZATION TO RELEASE EDUCATION RECORDS
TO A THIRD PARTY
Students enrolled in FGCU distance learning programs of study may mail, email or fax with valid photo ID to:
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