STUDENT AUTHORIZATION TO
RELEASE EDUCATIONAL RECORDS
Last Name First Name P#
The Family Education Rights and Privacy Act of 1974 provides privacy protection of a student’s education records and
limits the release of such records without the student’s consent. The Act further provides that the educational institution
may disclose such records to a third party with the student’s written consent.
DECLARATI
ON:
I vo
luntarily authorize Lamar State College-Port Arthur officials to release my education records identified below to the
following Third Party:
Name:
Address:
Email:
Phone:
Records authorized for release:
STUDENT’S DECLARATION:
I acknowledge I am aware of this request to release my education records to the Third Party specified above. I attest that
I am the student signing this form. I understand the information may be released orally or in the form of written
records as preferred by the requester. This authorization remains in effect from the date executed until revoked
by me in writing and delivered to the Registrar’s Office. I further release Lamar State College-Port Arthur, the
Texas State University System, their Regents, Officers, Employees, Agents or Assigns, from any and all liability for
release of the above named education records/information and acknowledge that the educational institution is not
responsible for subsequent uses or disclosures of records once they are released pursuant to this authorization.
Student’s Signature
Date
Transcripts/grades
Class schedule
All
Other _____________________________________________________________
