Updated January 2019 SSC
Request to Release Information
Information must be printed or typed in black or blue ink. (Penciled forms will not be accepted.)
According to the Family Educational Rights and Privacy Act (FERPA), college students are
considered responsible adults and are allowed to determine who will receive information about
their educational records.
In order to release information to a third party, a written request must be submitted to Student
All fields are required.
Student Name: ______________________________________________________________
Last First Middle
Student ID number: ___________________________________________________________
Last 4 digits of SSN & Full DOB (Only use if Student ID is unknown): __________________________
What are you requesting?
____ Enrollment Verification for Term: ______________________
____ Copy of Acceptance Letter
____ Copy of Grade Card for Term: _______________
____ Other (please specify):_____________________________________________________
Release Information To:
Name of Third Party: __________________________________________________________
Last First Middle
Fax Number: _________________________________
Mailing Address: ________________________________________________________
Street City State Zip
Email: _________________________________________________________________
I affirm that I am the student named above. In compliance with FERPA, I hereby give my
written consent and authorize East Central College to release my record as noted.
Student’s Signature: __________________________________Date: _____________