STUDENT CONSENT TO RELEASE
PRIVACY RIGHTS OF STUDENTS
The Family Educational Rights and Privacy Act (FERPA) affords students certain rights with respect to their education records under Chapter 20,
United States Code, section 1232g and other implementing regulations. FERPA requires each student be notified annually of the rights accorded
them by FERPA. These rights include (1) The right to inspect and review their education records within 45 days of a request for access. (2) The right
to request an amendment to the education record if the student finds the records to be inaccurate, misleading, o in violation of their privacy rights.
(3) The right to provide written consent before the college discloses personally identifiable information from the student’s education records,
except to the extent that FERPA authorizes disclosure without consent. (4) The right to file a complaint with the U.S. Department of Education
concerning alleged failures by the college to comply with the requirements of FERPA. FERPA provides for a category of student information termed
“directory information” which is available to all persons upon request unless the student places a “confidential hold” on his/her records.
Student’s name, address, telephone number, date of birth, major field of study, participation in officially recognized activities and sports, weight and
heights of members of athletic teams, dates of attendance, degrees and awards received, and the most recent previous educational agency or
institution attended by the student.
Education records other than directory information may be released only with the written permission of the student or as otherwise permitted by
I, _________________________________________________, freely and voluntarily consent to the release of
information from my education to the following:
NAME OF PARTY TO WHOM DISCLOSURES MAY BE MADE
Name _________________________________________________ Relationship to Student _______________________
Address of Party ____________________________________________________________________________________
City __________________________________________________________ State ________ Zip ____________________
Phone _____________________________ Email address ___________________________________________________
Education Record(s) Which May Be Disclosed:
If no date is indicated, the consent will expire when the student ceases to be a student at FKCC.
One time use for: ____________________
Effective for current Academic Year only.
First Name _______________________________ M.I. ______ Last Name ______________________________________
FKCC ID/SSN __________________ Email Address ___________________________________ Phone ________________
Address _______________________________________ City ______________________ State _____ Zip _____________
I have completed all sections accurately and truthfully, including information verifying my identity.
Completed form must be returned to Enrollment Services. Please allow 30 days for processing the request.
Florida Keys Community College is an equal access/equal opportunity institution. Discrimination/harassment on the basis of color, race, ethnicity,
genetic information, sexual orientation, religion, gender, age, national origin, marital status or disability in admission to, or employment in, its
education programs or activities is prohibited. Please report any form of discrimination/harassment immediately to the College’s Equity Officer,
Kathleen Daniel. Office A-130, Human Resources, 5901 College Road, Key West Florida 33040, (305) 809-3248 or to the Office for Civil Rights of the
U.S. Department of Education.
FKCC STAFF USE ONLY
Date Received: Banner Entry: Date Entered: Initials:
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