Fillable STUDENT FERPA INFORMATION RELEASE FORM (Mt. San Antonio College)

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STUDENT FERPA INFORMATION RELEASE FORM (Mt. San Antonio College)

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Student Life Office
Mt. San Antonio College
Building 9C - Student Life Center
1100 N. Grand Ave
Walnut, CA 91789
909.274.4525
MT. SAN ANTONIO COLLEGE
STUDENT LIFE OFFICE
STUDENT FERPA INFORMATION RELEASE FORM
Student Name (As it appears on your records) Student ID Number Date of Birth
❒Yes ❒No
Telephone Currently Enrolled? Date
The Family Educational Rights and Privacy Act of 1974 (FERPA), is a Federal law that protects the privacy of your records
at Mt. San Antonio College (Mt. SAC). Under FERPA, Mt. San Antonio College is required to treat non-directory
information as private and protected information from individuals, other than the student. Third party individuals include
parents, legal guardians, spouses, etc. Therefore, your student records cannot be discussed with third parties (parent, sibling,
spouse, etc.) without your written consent. This form allows you to authorize the Student Life Office at Mt. San Antonio
College to discuss all details regarding your complaint/grievance or student conduct information to the person(s) you
designate.
STUDENT INFORMATION RELEASE & SIGNATURE
I authorize the Student Life Office at Mt. San Antonio College to discuss the information stated below to the persons I have
indicated below:
Type of Record:
❒ Complaint/Grievance. Please specify any exceptions:_____________________________________________
❒ Student Conduct. Please specify any exceptions:_____________________________________________
1)
2)
Person’s Full Name Relationship to you Date of Birth
I understand that this release is only valid for ❒current semester, ❒1 year to date or ❒permanent until removed, and that I
can revoke any portion of this authorization at any time by providing an updated/written statement.
____________________________________ ________________
Student Signature Date
Please submit this form in person to the Student Life Office or through your Mt. SAC e-mail account.
OFFICE USE ONLY
Received by: ____________________________________
Notes:
_________________________________________________________________________________________
________________________________________________________________________________________
Staff signature: ____________________________________
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STUDENT FERPA INFORMATION RELEASE FORM (Mt. San Antonio College)

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Completed 25 July 2020

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