Last updated 6/1/16
Permission to Disclose Education Records
Return completed form to Registrar’s Office (scan/email, fax, mail, or in person)
Nazareth College upholds the protection of student education records in accordance with the Family Educational
Rights and Privacy Act of 1974, as amended (FERPA). Other than directory information and specific exceptions
outlined by FERPA, Nazareth will disclose student education records only with the written consent of the student.
You m
ay grant Nazareth College permission to release information from your education record to a designated
third party by completing and submitting this form to the Registrar’s Office, Smyth Hall, Room 1. You must
complete a separate form for each third party to whom you grant access (exception - both parents living at the
same address may be listed on one form). Your authorization to disclose records will remain valid through your
enrollment at Nazareth College unless a written request to revoke is submitted to the Registrar’s Office. Please
note, it is Nazareth College policy not to release certain aspects of student records (e.g., registration, grades,
GPA) over the phone.
Requested by (Student) Recipient(s) of Record Disclosure
________________________________________ _______________________________________
Last Name, First Name Last Name, First Name
________________________________________ _______________________________________
Student ID Number SSN (Last 4 Digits)
________________________________________ _______________________________________
Street Address Street Address
________________________________________ _______________________________________
Address (City, State, Zip) Address (City, State, Zip)
________________________________________ _______________________________________
Email Email
________________________________________ _______________________________________
Phone Phone
I, _____________________________, give permission for my academic education record information
(includes course grades and GPA information) to be disclosed to the above named designee(s). By
signing below, I indicate my understanding of my rights under FERPA.
NOTE: Permission to view/discuss financial information (billing and loans) must be requested through
: click View Account and Make Payments in the Financial section. At the next screen, click on your
first name (upper right toolbar), and select View/Add Person Proxy. Follow the steps outlined.
________________________________________________ _______________________
Student Signature Date
For Office Use Only:
PERC Code Added: Processed By:
Office of the Registrar • Smyth 1
4245 East Ave • Rochester, NY 14618
Phone (585) 389-2800 • Fax (585) 389-2612