Updated 7/24/15
Oce Use Only
Date Received:
Photo ID Veried: Inials:
RELEASE OF INFORMATION CONSENT FORM
The Family Educaonal Rights and Privacy Act (FERPA) prohibits the instuon from disclosing student records, or informaon from
those records, to anyone other than the student to whom the records pertain, unless the instuon has the student’s consent.
FERPA protects transcripts, grades, exams, and the like, but it also protects virtually all other records, in any format, that contain
personally idenable informaon about a student (student informaon database, class schedules, nancial account, disciplinary
records, “unocial” records, photographs, and emails). By signing this form, the student gives permission to the instuon to share
certain pieces of informaon with the designated individual.
Student: ___________________________________________________________________ Manhaan Tech ID#: ______________
Mark the areas for which you consent to the release of your informaon:
__ Aendance __ Grades
__ Disciplinary Referrals/Acons __ Student Account
__ Financial Aid __ Other (Specify) ____________
Indicate whom the informaon can be released to:
Name: __________________________________________________ Name: _____________________________________________
Phone: __________________________________________________ Phone: ____________________________________________
Relaonship: _____________________________________________ Relaonship: _______________________________________
This consent form is eecve from the date acvated unl cancelled by the student. This form is not mandatory.
_________________________________ __________________________ ____________________
Student Signature Date Acvated Date Cancelled
