CR Last updated 12/18/2012
Name of Student (Last, First, Middle):
Student ID:
The Family Educational Rights and Privacy Act (FERPA) affords certain rights to students concerning the privacy of and access to
their education records. Students may choose to complete and submit this form to the Registration and Records office allowing the
release of their education records to specified third parties. Please note that while this form authorizes ECC to release education
records to third parties, it does not obligate ECC to do so. ECC reserves the right to review and respond to requests for release of
education records on a case-by-case basis.
SECTION A. Education record to be released (check all that apply):
Academic Information (midterm grades, final grades and GPA)
Financial Aid Information
(awards, application data, disbursements, eligibility, financial aid academic progress
Loan Information (loan disbursements, communications history and balances)
Student Account Information (billing statements, charges, credits, payments, past due amounts, collection
All records listed Above
SECTION B. Person(s) to whom access to education records may be provided:
Last Name First Name Relationship to Student Address
Last Name First Name Relationship to Student Address
Last Name First Name Relationship to Student Address
SECTION C. Duration of release (check one):
One-Time Use: This authorization can be used only once.
Limited Use:
This information will be valid until revoked by the student or until the student is no longer enrolled
at the college.
SECTION D. Purpose of release:
Please specify
I understand that (1) I have the right not to consent to release my education records, (2) I have the right to inspect any
written records released pursuant to this Consent, and (3) I have the right to revoke this consent at any time by delivering
a written revocation to the Registration and Records Office.
Student’s Signature Date
Staff Witness Signature Phone Ext. Date
Instruction for completing this form:
1. This form must be fully completed and signed by the student in the presence of an ECC staff witness.
2. If unable to sign this form in the presence of an ECC staff witness, we can still accept the form if the signature is notarized.
The form should be mailed to: Elgin Community College, Attn: Records Office, 1700 Spartan Dr., Elgin, IL 60123.