from my education record to the following:
NAME NAMERELATION TO STUDENT RELATION TO STUDENT
CITY CITY
ADDRESS OF PARTY ADDRESS OF PARTY
PHONE PHONE
ADDRESS CITY
STATE STATEZIP ZIP
FIRST NAME M.I.
LAST NAME
PHONEEMAILVALENCIA ID/SOCIAL SECURITY NUMBER
THE AUTHORIZED PERSON WILL BE REQUIRED TO PRESENT PHOTO IDENTIFICATION WHEN SUBMITTING THE FORM.
Purpose of Disclosure: _______________________________________________________________________________________
Note that presentation of this form does NOT entitle the bearer to conduct business on behalf of the student.
Education Record(s) Which May Be Disclosed:
q All Education Records q Other (please specify) _____________________________________________________________
Period of Time During Which Consent Shall Be Valid From: __________________________ To: _________________________
If no date is indicated, the consent will expire when the student ceases to be an active student at Valencia College.
STUDENT INFORMATION
© 2018 Valencia College |
NAME OF STUDENT (Please print clearly)
SIGNATURE PRINTED NAME DATE
NAME OF PARTY TO WHOM DISCLOSURES MAY BE MADE NAME OF PARTY TO WHOM DISCLOSURES MAY BE MADE
STATE ZIP
I have completed all sections accurately and truthfully, including information verifying my identity.
The completed form along with a copy of photo identification can be submitted at an Answer Center on any of our campuses.
Please allow 45 days for processing the request.
STUDENT CONSENT TO RELEASE
EDUCATION RECORDS
ADMISSIONS AND RECORDS
PRIVACY RIGHTS OF STUDENTS
The Family Educational Rights and Privacy Act (FERPA) aords 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, or 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.
DIRECTORY INFORMATION includes only these four pieces of student information:
1) Student's name 2) Major field of Study 3) Dates of attendance 4) degrees, honors, and awards received
Education records other than directory information may be released only with the written permission of the student or as otherwise
permitted by law.
I, ___________________________________________________ _____________ freely and voluntarily consent to the release of information
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signature
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