Cosumnes River College
District Office
STUDENT CONSENT FOR RELEASE OF STUDENT RECORDS
Student Information
Full Name Student ID#
Street Address City State Zip Code
Telephone Number
Under Federal legislation, namely the “Family Educational Rights and Privacy Act of 1974” (FERPA), I understand that generally my educational
records cannot be released without my written permission. This form will serve as your authorization to disclose your student record
information to a third party. A records release is limited to a catalog year, which begins before fall semester (June 1st) and ends after spring
semester (May 30th). This request form is intended as a one-time-only use for each specific category of records you want released by the college
(but your authorization may span over a Catalog year). You must submit a separate request for each category of records you seek to be released.
This request is solely for the release of recorded information, and this form does not grant a discussion of student records or students.
I, therefore, request that the information listed below be released to the following:
Name
Street Address
City State Zip Code
Category of Information to be released:
Admissions and Records
Athletic Eligibility Records
CalWORKs Records
EOPS Records
Financial Aid Records
International Student Records
Other Program Records (Describe below)
Signed this
day of
Student Signature
Processed By:
Office Use Only
Date Processed:
Why are you requesting the release of your records? (Please explain briefly)
Title or Relationship
Student Account Financials
Transcripts
Veterans Records
Day
Month
Year
Rev. 3/16/2016
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/
This Form is for the Release of Recorded Information Only
Department:
Scan Doc Type: FERPA RELEASE
Attach to Athletics Dept. Release Form
Date:
/
/
Date:
/
/
Release Begins:
Release Ends:
Optional: Please specify which record you give consent to release. (Please explain briefly)
