Updated 7/24/15
Oce Use Only
Date Received:
Photo ID Veried: Inials:
The Family Educaonal Rights and Privacy Act (FERPA) prohibits the instuon from disclosing student records, or informaon from
those records, to anyone other than the student to whom the records pertain, unless the instuon 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 idenable informaon about a student (student informaon database, class schedules, nancial account, disciplinary
records, “unocial” records, photographs, and emails). By signing this form, the student gives permission to the instuon to share
certain pieces of informaon with the designated individual.
Student: ___________________________________________________________________ Manhaan Tech ID#: ______________
Mark the areas for which you consent to the release of your informaon:
__ Aendance __ Grades
__ Disciplinary Referrals/Acons __ Student Account
__ Financial Aid __ Other (Specify) ____________
Indicate whom the informaon can be released to:
Name: __________________________________________________ Name: _____________________________________________
Phone: __________________________________________________ Phone: ____________________________________________
Relaonship: _____________________________________________ Relaonship: _______________________________________
This consent form is eecve from the date acvated unl cancelled by the student. This form is not mandatory.
_________________________________ __________________________ ____________________
Student Signature Date Acvated Date Cancelled