STUDENT CONSENT TO WITHHOLD
EDUCATION RECORDS FORM
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:
• Student’s name
• Major field of study
• Dates of attendance
• Dates of degrees or 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.
LAST NAME
ADDRESS CITY STATE ZIP
FIRST NAME M.I.
PHONE EMAIL
MAIDEN NAME
VALENCIA ID/SOCIAL SECURITY NUMBER
STUDENT INFORMATION
Please type or print in ink your name as it currently appears on your Valencia records.
Student’s Signature: ______________________________________________________________
Printed Name: ____________________________________________________________________
Date: ________________________________________
© 2015 Valencia College | 14ADM015
NAME OF STUDENT (Please print clearly)
I, _____________________________________________, request that Valencia College withhold the release of my directory information,
unless I specifically authorize the release of the information in writing.
I understand that by submitting this request my name will not appear in any publications including, but not limited to, President’s
and Dean’s lists.
The completed form can be submitted at an Answer Center on any of our campuses.
click to sign
signature
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