Student Reference Request, FERPA Release,
and Release of Liability
Student name: _____________________________________ ID: _______________
I request ___________________________________________ to serve as a reference for me.
(name of faculty or staff member)
The purpose(s) of the reference are: (check all applicable items)
application for employment
admission to another educational institution
all forms of scholarship or honorary award
other: __________________________________________________________
The reference may be given in the following form(s): (check one or both items)
written oral
I authorize the above named person to provide an evaluation of any aspect of my academic
performance, whether based on personal observation or on my education records at Southern,
and to release information from my education records, including my grades, GPA, class rank,
any information pertaining to my education at other institutions I have previously attended, and
any other personally identifiable information. I authorize release of this information and
reference or evaluation to: (check all applicable items)
all prospective employers OR
specific employers (list name and address on a separate sheet)
all educational institutions to which I seek admission OR
specific educational institutions (list name and address on a separate sheet)
all organizations considering me for a scholarship or award OR
specific organizations (list name and address on a separate sheet)
other: __________________________________________________________
I understand that under the Family Educational and Privacy Rights Act, 20 USC 1232g: (1) I
have the right not to consent to the release of my education records; (2) I have the right to
receive a copy of any written reference upon request; and (3) I may, but am not required to,
waive my right of access to confidential references given for any of the purposes listed above.
I waive my right of access to references given by the above named person.
I do not waive my right of access to references given by the above-named person.
This release shall remain in effect until revoked by me, in writing, and delivered to the above
named person, but any such revocation shall not affect disclosures made prior to the person’s
receipt of my written revocation. I release Southern Adventist University, its employees and the
person(s) providing the above described reference or evaluation from all claims and liability for
damages that may result from their from their compliance with this request.
_____________________________________ _________________________
(Student signature) (Date)
Used by permission of Bob Brown, Ph.D. of Kennesaw State University Marietta Campus