Return To: Records and Registration
Enrollment Center, Sage Hall, Room 1020
One University Drive
Camarillo, CA 93012
(805) 437-8500
Please Note:
FERPA Authorization Form for 2016-2017
Section A: Student Information
Student ID# Date of Birth First Name Last Name
Section B: Third-party Designee
First Name Last Name Relationship Date of Birth
Authentication
When the party named above contacts California State University Channel Islands (CSUCI), s/he will be asked to authenticate her/his
identity by providing a special identifier code. You, the student, should create this identifier and provide it to your third party
contact. Do not choose an identifier that could easily be guessed. If your third party contact is not able to correctly provide the five
digit identifier, CSUCI will not release any information from your record. If you forget or misplace your five digit identifier, CSUCI can
provide it to you in person (by visiting the Enrollment Center and providing a photo ID) or in writing upon request (will be sent to
your email address on file). The identifier must include exactly two (2) letters and three (3) numbers (e.g. HT515).
____________
Two (2) Letters
Section C: Infor
mation Types Allowed (check one or more boxes to grant authorization)
Grades/GPA, demographic, registration, student ID number, academic progress status, and/or enrollment information
Billing statements, charges, credits, payments, past due amounts, and/or collection activity
Financial aid awards, application data, disbursements, eligibility, and/or financial aid satisfactory academic progress
University-maintained loan disbursements, billing and repayment history (including credit reporting history), communication
history, balances and/or collection activity
All of the above
Section D: Authorization Student Signature
The Family Education Rights and Privacy Act of 1976, as amended and contained in the Code of Regulations (34CFS 99,
subpart D99.30), requires a written and dated consent from any student in attendance before disclosing personally
identifiable information from the student’s educational, financial, all other records to a third party. Under the Family
Education Rights and Privacy Act (FERPA), CSUCI reserves the right to withhold student information from a third party.
• This form must be
submitted in person
by the student to Records & Registration in the Enrollment Center.
• This authorization is in effect until you request, in writing, otherwise or until 30 days after the end of the 2016-2017 academic
year {June 26, 2017}.
Student Signature
Date Signed: mm/dd/yyyy
Administrative Use Only – Records and Registration: Processed by: ______________ Student Notification: ______________
(Staff Initials)
(Date)
http://www.csuci.edu/records-registration/rec_reg_library.htm
_____________
Three (3) Numbers
(Submit one form per designee)
