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Rec Eval Waiver FORM26-RecEvalWaiver.pages

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Updated 12/2018
Saint Louis University
Recommendation/Evaluation
Authorization and Waiver
Form
#26
Enrollment Services Center - DuBourg Hall, Room 119
1 Grand Blvd. St. Louis, MO 63103 314.977.2269 www.slu.edu/questions
Section 1
Student
Student Name
Student ID
Section 3
Type
Letter of Recommendation
Evaluation Form
Type of disclosure. Check all that apply.
Other
Section 2
School Official
Saint Louis University official making recommendation or evaluation
Name
Department
The Family Educational Rights and Privacy Act (FERPA) affords certain rights to students concerning
the privacy of, and access to, their education records. In order to submit recommendations or
evaluations in accordance with FERPA regulations, school officials must request that students submit
this authorization/waiver or its equivalent prior to providing FERPA-protected student information to
third parties. For additional information regarding FERPA, please visit http://ferpa.slu.edu or the U.S.
Department of Education’s website at www.ed.gov/policy/gen/guid/fpco/ferpa/index.html.
Section 4
Release
Any Educational Institution
All Potential Employers
Person(s) to whom education records may be disclosed. Check all that apply.
Any Scholarship or Award Granting Organization
Saint Louis University
Recommendation/Evaluation
Authorization and Waiver
Form
#26
Enrollment Services Center - DuBourg Hall, Room 119
1 Grand Blvd. St. Louis, MO 63103 314.977.2269 www.slu.edu/questions
Section 7
Authorization
Student Signature
Date
✴ By signing below, I authorize the official named in Section 2 to consult my education records
and to disclose such education records as that official considers appropriate in accordance
with the above-stated purpose(s).
✴
I understand that I have the right to revoke this authorization/waiver at any time by
delivering a written revocation to the official named in Section 2, but that such revocation will
not affect any waiver of access to records obtained or received prior to delivery of such
written revocation. I also understand that a copy of this authorization/waiver may be sent
with the recommendation(s)/evaluation(s).
I understand and acknowledge that:
1. Student completes sections 1, 2, 3, 4, 5 and 6.
2. Student acknowledges policies related to recommendations and evaluations authorization and
waiver by signing in section 7.
3. Student submits to official named in Section 2.
4. School official named in Section 2 retains original form.
Form Procedures
Section 6
Review
I waive the right to review the requested recommendation(s)/evaluation(s).
I DO NOT waive the right to review the requested recommendation(s)/evaluation(s).
Waiver of Review. Check one.
Section 5
Purpose
Admission to an Educational Institution
Employment
Purpose of disclosure. Check all that apply.
Other
Application for a Scholarship/Fellowship/Grant/Award
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Completed 19 March 2020

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