For Office Use Only
This student's records were accessed by __________________________________________(Relationship to Student)_________________
Print Name
on the _____ day of ______________ 20____.
____________________________________________
Signature of Recipient
Student's signature and Recipient's credentials verified by ____________
PBSC Staff Initials
Privacy of Student Records
In this day and age, privacy of personal information is paramount on the minds of many private citizens.
Palm Beach State takes the protection of the student and their records VERY seriously and, therefore, will
follow the law in order to serve the student's best interest.
The Family Educational Rights and Privacy Act of 1974 (FERPA) allows the release of "Directory
Information" without the student's prior consent. This includes dates of attendance, major field of study,
weight and height of members of athletic teams, degrees and awards received, and educational institutions
attended. A student may request that ALL information be considered private and therefore not
released to anyone by submitting a non-disclosure form located online at www.palmbeachstate.edu/
PantherWeb. (Log in to PantherWeb and click on the “Don’t Share My Information” button, located at
the top right corner of the home page.).
With regard to parental access to a student's file: The Guidelines for Postsecondary Institutions for
Implementation of the Family Educational Rights and Privacy Act of 1974 as Amended-Revised Edition
1995 states: "At the postsecondary level, parents have no inherent rights to inspect a student's education
records. The right to inspect is limited solely to the student." Records MAY be released only through
express written permission by the student or in compliance with a subpoena.
If a parent, guardian, spouse, or other person wishes to gain access to a student's records by obtaining
written request, they may use the form provided below.
Photo identification must be provided by any person requesting access to a student's records.
Palm Beach State College
RELEASE OF INFORMATION FORM
I, _____________________________________, Student ID ______________________, request that any
and all information in my student record be released to __________________________________ (photo
ID required)
. I understand that this release is only valid for one use and must be resubmitted should
anyone need access to my records again. You may reach me at (daytime phone number)
___________________ if you require additional information. When I attended Palm Beach State, my
name was ___________________________.
(print previous name if different from above)
Student's Signature (required): ____________________________________ Date: ___________________
Student signature WILL be compared to the signature contained in the student's file.
