Fillable RELEASE OF INFORMATION FORM (Virginia State University)

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RELEASE OF INFORMATION FORM (Virginia State University)

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RELEASE OF INFORMATION FORM
With your approval, the Virginia State University Peace Corps Preparatory (PC Prep) program
will release information on a regular basis to the Peace Corps, including details about the
participants in this program and other relevant data that help the Peace Corps evaluate the
effectiveness of PC Prep. These educational records are subject to the Family Educational
Rights and Privacy Act (FERPA), a Federal law designed to protect the privacy of a student’s
educational records. This Act prohibits college officials from disclosing any records, including
grade reports, academic standings, transcripts of records, or any other records, which contain
information directly related to the student and from which the student can be individually
identified without the student’s consent. Consistent with FERPA guidelines, Virginia State
University will not release records related to your performance in the PC Prep program, other
than those enumerated in this disclosure agreement.
I hereby permit Virginia State University to disclose personally identifiable information to
Peace Corps regarding my participation in the Peace Corps Preparatory program for the
purposes of evaluating PC Prep. This information will be limited to my name, date of
admission to PC Prep, the coursework and other activities I pursued to satisfy PC Prep
requirements, date of graduation, and whether I successfully completed the PC Prep upon
graduation. If I do not ultimately enter the Peace Corps, Virginia State University may report
post-graduation career information to the extent that Virginia State University has that
information.
Student Name (printed) ___________________________________________________
Student Signature_________________________________________________________
Date_____________________
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Completed 24 July 2020

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