JSRCC Form 11-0020 Release of Information form 11-2019
Release of Information
In accordance with the Family Educational Rights to Privacy Act (FERPA), J. Sargeant Reynolds Com-
munity College protects the personally identifiable information within students’ educational records.
FERPA limits the release of educational records, except in those cases where a student provides written
authorization. By completing this form, you are authorizing J. Sargeant Reynolds Community College to
release information contained within your records.
This release will remain in effect for one semester , or until a date prior to the end of the indicated semester.
Student ‘s Name: EMPL ID:
Email address: Phone number:
The above named student authorizes J. Sargeant Reynolds Community College to disclosed the following information:
Admissions Records Financial Aid Records Student Conduct Records
Placement Test Information Student Financial Records (tuition) Transcript (Grades)
What information do you want released?
Enrollment Verification (processed after the last day to drop with a refund)
Semester(s): Fall Semester Spring Semester Summer Semester
What information do you want released?
Course Information: Semester Course Section All courses for semester
What information do you want released?
The information will be provided to:
Name and address or name and email address Relationship to student:
I understand that with a written request I can revoke access to my record before the end of the semester indicated. I further
understand I can inquire about my record by telephone or email by providing a password.
I am revoking access to my record as of : Password:
(Used for telephone or email inquiries)
Student Signature: Date:
JSRCC-Registrar’s Office
Post Office Box 85622
Richmond, VA 23285-5622
Telephone:804-523-5030—Fax: 804-371-3650
Email: Registrar@reynolds.edu
FALL SEMESTER (Aug - Dec) 20 SPRING SEMESTER (Jan - May) 20 SUMMER SEMESTER (May - July) 20
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