Mt
.
San
Antonio
College
I
MT. SAN ANTONIO COLLEGE
STUDENT LIFE OFFICE
REQUEST FOR STUDENT LIFE RECORDS
Student Name (As it appears on your records) Student ID Number Date of Birth
Currently Enrolled?
Yes
No
Telephone Last attendance at Mt. SAC
Type of Record:
Academic Grievance. Please specify:
Student Conduct. Please specify:
The Family Educational Rights and Privacy Act of 1974 (FERPA), is a Federal law that protects the
privacy of your records at Mt. San Antonio College (Mt. SAC). Under FERPA, Mt. SAC is required to
treat non-directory information as private and protected information from individuals, other than the
student. Third party individuals include parents, legal guardians, spouses, etc. Therefore, your student
records cannot bet be discussed with third parties (parent, sibling, spouse, etc.) without your written
consent.
Student Signature Date
Please allow for 10 business days for your request to be processed.
Documents will be sent to your mailing address on your student portal via USPS Certified
mail.
Digital files will be sent to your Mt. SAC student email address via Mt. SAC Dropbox (up to
digital file size limit).
Please submit this form in person to the Student Life Office or through your Mt. SAC e-
mail account.
Office Use Only
Received by:
Date Sent:
Notes:
Staff Signature:
Student Life Office
Mt. San Antonio College Building
9C - Student Life Center
1100 N. Grand Ave
Walnut, CA 91789
909.274.4525
click to sign
signature
click to edit
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