Name of Student: (Last, First, Middle Initial)
Student ID:
Date of Birth:
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
Registrar allowing the release of their education records to specified third parties. While this form authorizes
Monroe College to release education records to third parties, it does not obligate Monroe College to do so.
Monroe College reserves the right to review and respond to requests for release of education records on a case-
by-case basis.
Section A: Education records to be released (check all that apply):
Registrar Information (grades, GPA, registration, academic progress, enrollment status, attendance
Financial Aid Information (awards, FAFSA application data, disbursements, loan information,
eligibility, status, housing status)
Student Account Information (billing statements, tuition charges, refunds, payment information,
account status (i.e. past due amounts collection activity)
Student Conduct Records (student misconduct incident reports, disciplinary hearing results)
All of the above
Section B: The following persons may have access to my records: Relationship (parent) (guardian)
(spouse) (other).
Last Name
First Name
Address and Contact Number
Section C: Password:
You must establish a password with the individuals listed in Section B before we can provide access to
information from your student educational records. We will not release any information from your records (other
than directory information) unless the person(s) named above provides this password. For a description of
directory information go to → About Monroe → Right to Know → Family Educational
Rights and Privacy Act. Your password must contain a minimum of 6 characters and must consist of letters and
numbers. My password is: _______________________.
By signing below, I voluntarily authorize Monroe College to release indicated information to the third parties listed
on this form after verifying their identity via the required password. I also understand that I have the right to
revoke this consent at any time by submitting a written revision of the form to the Office of the Registrar.
Student’s Signature: ________________________________________ Date: ___________________________
Rev. 06/16/20
Bronx Campus
2501 Jerome Avenue
Bronx, NY 10468
New Rochelle Campus
434 Main Street
New Rochelle, NY 10801
click to sign
click to edit