Fillable Student Consent for Disclosure of Education Records (Fontbonne College)

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Student Consent for Disclosure of Education Records (Fontbonne College)

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File type: PDF

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Student Consent for Disclosure of Education Records
________________________________________________________________________________________________
Name Student ID # OR LAST 4 DIGITS of SSN
________________________________________________________________________________________
Address Phone
The Family Education Rights and Private Act of 1974, as amended (“FERPA”), protects the privacy of students’ education
records maintained by Fontbonne University. The University cannot disclose the information contained in those records to
anyone without a student’s permission, except in limited circumstances in accordance with FERPA.
The FERPA or Buckley Amendment allows the university to respond to parents, stepparents, grandparents, spouse,
employer, or any third party inquiries. Fontbonne University will not be able to talk with anyone other than the student,
regarding any records including academic, disciplinary, and financial, without this written consent form on file.
I hereby consent to the University’s disclosure of certain information from my education records to the person(s) described
below (please check all areas that apply):
___________________________________________________________________________________________________
Name Relationship
Allowable disclosure of records: □Academic □Disciplinary □Financial
___________________________________________________________________________________________________
Name Relationship
Allowable disclosure of records: □Academic □Disciplinary □Financial
___________________________________________________________________________________________________
Name Relationship
Allowable disclosure of records: □Academic □Disciplinary □Financial
___________________________________________________________________________________________________
Name Relationship
Allowable disclosure of records: □Academic □Disciplinary □Financial
___________________________________________________________ ______________________________
Student Signature (physical signature required) Date
Fontbonne University’s FERPA policy is posted on the website at www.fontbonne.edu. Search under FERPA.
Please return this form to the Office of the Registrar Ryan Hall 205
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Student Consent for Disclosure of Education Records (Fontbonne College)

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Completed 29 January 2021

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