Office of Admissions and Student Records
Revised 10/2014 Address: 601 E. College Drive, P.O. Box 270 Winnebago, Nebraska 68071 Phone: 402.878.3307 Fax: 402.878.2309 Website:
Disclosure to Third Party of Students and Consent Form for Disclosure to Third Party
________________________ _________ ________________________ _________________
Student’s First Name Initial Last Name ID #
Mailing Address Street Address City State Zip Code
Under the Family Educational Rights and Privacy Act (FERPA), Little Priest Tribal College is permitted to disclose
information from your education records to a third party only if the student consents in writing. Please indicate
what information may be disclosed and to whom it may be disclosed.
Please check the appropriate box:
The following information may be disclosed to the named third party.
____ Financial Aid Information ____ Business Office information
____ Academic Information ____ Bookstore charges
____ Application Information ____ Other ___________________________
Do not release any information to a third party.
I consent to the disclosure of any personally identifiable information from my education records to the following
third party for reasons determined by Little Priest Tribal College as appropriate. A new form must be completed for
each school semester.
Signature ________________________________ Date ___________________________
The following third party or parties may receive information concerning the above named records.
1. ________________________________ 2. ___________________________________
Name(s) Name(s)
________________________________ ___________________________________
Address Address
_________________________________ ___________________________________
City, State, Zip City, State, Zip
_________________________________ ___________________________________
Telephone Telephone
*Students cannot be denied any educational services from Little Priest Tribal College if they refuse to provide
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