Fillable Permission to Release Student Records FERPA (University of Baltimore)

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Permission to Release Student Records FERPA (University of Baltimore)

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Permission to Release Student Records FERPA
The Family Educational Rights and privacy Act (FERPA) is a Federal Law that protects the privacy
of a student’s educational record. Detailed information can be found on the UB website:
www.ubalt.edu/ferpa
The undersigned student permits the University of Baltimore to disclose specified information
to individuals or organizations. Students authorizing the release of their educational records
must sign and present this form to the Office of Records and Registration with a photo ID.
Please provide a password to obtain information via the phone: ________________________
The password must be a combination of 8 - 10 letters and numbers that you can provide to the
individuals or agencies below. The information will not be released to the caller if they do not
have the password.
Student information Recipient information
_____________________________________
_____________________________________
last name, first name
last name, first name or organization name
__________________________________________________
__________________________________________________
student ID number
relationship: parent/guardian, spouse, other
__________________________________________________
__________________________________________________
address
address
__________________________________________________
__________________________________________________
city, state, zip
city, state, zip
Indicate the records you wish to release:
____ All Academic Records (grades, schedules, registration, academic status, and other
information as it relates to student’s academics).
____ All Financial Records (status of awards and disbursements, billing, financial holds,
scholarships and other information as it relates to student’s financial account).
Student Signature________________________________________ Date: __________________
Office of Records and Registration processing:
By: ____________________________________________________ Date: __________________
This form will remain in effect until the student revokes access or is no longer enrolled at the
University of Baltimore.
Forward completed form to:
University of Baltimore | Office of Records and Registration
Academic Center, Room 126 | 1420 N. Charles St. Baltimore, MD 21201
E: records@ubalt.edu | T: 410.837.4825 | F: 410.837.4820
Office of Records and Registration 11/30/2017
REVOKE ACCESS
I understand that I may revoke this consent at any time by signing below and forwarding the
request to the Office of Records and Registration.
I hereby cancel all permissions to release information effective: _______________________
Student Signature: ___________________________________ Date:___________________
Office of Records and Registration
Processed by: _______________________________________ Date:___________________
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Permission to Release Student Records FERPA (University of Baltimore)

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Completed 28 August 2020

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