Office of Admissions & Records, Bldg.700
25555 Hesperian Boulevard • Hayward, California 94545
Email: ccaracom@chabotcollege.edu
PL:rb revised 7/25/2019
STUDENT RELEASE OF RECORDS
FERPA RELEASE FORM
(Family Educational Rights and Privacy Act)
TO BE FILLED OUT BY THE STUDENT ONLY.
I, __________________________________ hereby authorize Chabot College to release my educational records, as indicated below, for the purpose of:
(Student requesting release, print full name)
Academic Assistance Payment of tuition Verification of Enrollment/Progress Concurrent Enrollment for Young Minor
Other (specify): ________________________________________________________________________________________________________________________
Initial on the lines below to indicate which records you wish to make available:
_______ All Academic/Transcript Records (records include: transcripts, admission and registration information, schedule information, assessment test scores,
Satisfactory Academic Progress status, residency information, and any other documentation contained in the academic records.)
_______ All Student Account Records (records include: amounts due for tuition and fees, sources of payment for tuition and fees, refund information as it relates to
parking tickets, library fines, financial aid repayments and any other accounts receivable information contained in student account records.)
_______ All Financial Aid Records (records include: status of file, award and disbursement of funds information. Satisfactory Academic Progress
status, income information, and any other information contained in the application or financial aid file.
_______ Other (please specify) ____________________________________________________________________________________________________________
Please Note: Counseling Center and Services for Students with Disabilities records are considered medical records and are not covered under FERPA rules. A separate
release form must be obtained from these departments.
The following individual(s) are authorized to access the information indicated above:
PLEASE PRINT FULL NAME
Spouse : ________________________________________________________
Mother/Guardian:_________________________________________________
Agency:_________________________________________________________
Father/Guardian: _________________________________________________
Other: _________________________________________________________
(Specify name and relationship)
Emergency Contacts
IN CASE OF AN EMERGENCY, PLEASE NOTIFY:
I understand I am not required to release this information; I am giving my consent to Chabot College to disclose these records. I also understand that this release remains in
effect for one calendar year from the date signed, unless I revoke my consent in writing and deliver it to the Office of Admissions and Records at Chabot College.
NOTE: A clear photocopy of your picture ID is required to verify authenticity of this release. Chabot College can make a copy if you deliver this form in person. Otherwise,
please make sure a copy is attached before turning this form in.
FERPA pertains to the release of records only. It does not give others the right to act on your behalf or to change your records.
Student Signature __________________________________________________________________ Date_________________________________________
Student “W” ID # ________________________________________________________________________________________________________________________
Address: _______________________________________________________________________________________________________________________________
Number and Street Apt. Number
_______________________________________________________________________________________________________________________________________
City State Zip Code
Original must be kept on file with Chabot College Office of Admissions and Records. A copy will be sent to the student. Upon request, a copy will be sent to the appropriate
campus offices for their files.
You must submit this form with a photo ID either in-person, postal mail, or email to: Chabot College, Admissions and Records, 25555 Hesperian Blvd., Hayward, CA
94545, email to ccarcom@chabotcollege.edu (you must use your zonemail account if you will be sending this form via email).
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