STUDENT CONSENT FORM TO RELEASE INFORMATION
Family Educational Rights and Privacy Act (FERPA) of 1974
20 USC § 1232g and 34 CFR § 99
Instructions to Student
: Carefully read the information below. After completing the form,
submit it to the Pierce College faculty/staff/office you authorized to release your
information.
In accordance with the Family Educational Rights and Privacy Act (FERPA) of 1974, Pierce College
must obtain written consent from a student before releasing the educational records of that student to a
third party. Such written consent must be signed and dated by the student, specify the records to be
released, state the purpose of the release, and identify the party or class of parties to who release may be
made.
I ________________________________________________
(Student’s Name-Print)
,
(Student ID #)
________ - _______ - ________
hereby give my written consent to_________________________________________________
(Pierce College Faculty/Staff/Office)
to release my
_____________
_____________________________________________________
(Specify records to be released)
to
___________________________________________________________________________
(Identify the person(s) to whom release may be made)
for the purpose of _____________________________________________________________.
(State the purpose of the release)
I understand th
at the information will only be released over the telephone to my authorized third party
when s/he provides the Pierce College staff member authorized to release the information with the
following password: .
____
(Write password here)
I understand that my written consent will rema
in in effect until I notify the Pierce College
employee/office named in this form, in writing, to cancel it.
I understand that the specific information referenced on this form is being released to a third party at my
request with the understanding that s/he will not release it to any other parties. Pierce College is hereby
released from all legal responsibility or liability for the release of the above-mentioned information.
Student’s Signature: _________________
________________________
Date: ____________
Pierce College is required to keep the original signed consent form. Students are advised to keep a
copy of this consent form with their re
cords.
For Registration Office Use Only: Receipt Date ________ Staff Initial ________ U.A. Code Entered __________
ctj-10/00;05/03
_________________________________________________
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