The Family Education Rights & Privacy Act (FERPA) is a federal law which influences record keeping in most colleges and
universities. It is popularly known as the “Buckley Amendment”. The law requires that the educational records of students
in colleges and universities receiving Department of Education funds remain confidential. The Buckley Amendment allows
others to access a student’s educational records only if the student consents.
Students must present a photo ID with this form.
Forms submitted by fax or mail must include a copy of the student’s photo ID.
Name: ____________________________________ Student ID: ___________________________________________
DOB: ____________________________________ Phone: _______________________________________________
I authorize the designated staff at LRCC to release the following information:
CHECK ALL AREAS THAT APPLY
General Academic Progress
*I understand this release of information does NOT allow access to the Student Information System (SIS) or grades,
final grades or official transcripts.
The following individual(s) have permission to discuss the information specified above:
Name: _________________________________Phone: ____________________ Relationship: ___________________
Name: _________________________________Phone: ____________________ Relationship: __________________
This authorization will remain in effect indefinitely, or until the student named above notifies the Registrar’s Office
directly. Changes to this form may be submitted in writing at any time.
Signature: ____________________________________________________ Date: _____________________________
Authorization to Release Student Information
Office of the Registrar
379 Belmont Road, Laconia, NH 03246
Phone: (603) 524-3207 Fax: (603) 524-8084
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