Rapid City, SD 577034018
605718-2400 Fax: 6053942204
Toll Free: 18005448765
Student’s Name: ______________________________________ Student ID#:___________________
(Not Social Security #)
In accordance with the Family Educational Rights and Privacy Act of 1974 (FERPA), Western Dakota
Tech (WDT) must receive a student’s authorization to permit WDT to release academic and financial
information to third parties.
Students requesting WDT to provide academic and/or financial information to a third party must submit
this completed Authorization to Release Information to the registrar’s office before WDT can provide the
information to any third party on behalf of the student.
The undersigned student hereby permits Western Dakota Technical Institute to release the following
information (check all that apply):
Academic Records Financial Records
to the below-specified persons/agencies:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
Name: ________________________________________________________________________
Address: ______________________________________________________________________
Information will only be released upon verification of identity of the specified above persons/agencies.
A valid ID, personal identification number (PIN), or password may be presented to confirm identify. The
PIN or password that I choose to serve as identity verification will be___________________________.
I understand that it is my responsibility to provide the above specified persons/agencies with this PIN or
password if I so choose. I acknowledge that it is my responsibility to ensure the PIN or password I have
chosen remains secure.
This consent to release information shall be valid throughout the student’s application for enrollment and
during a student’s enrollment. This authorization may be rescinded at any time by the student by
submitting a written statement to WDT’s registrar’s office.
I have read and understand the contents of this consent form pertaining to the Family Educational Rights
and Privacy Act of 1974.
Student’s Signature: ________________________________________________ Date: ______________
Internal use:
Permissions Updated PIN/Password Entered by _________ (initials) on _______________ date