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
______________________________________________________________________________________________
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
Student Consent for Disclosure of Education Records
Page 1 of 1
Fontbonne University’s FERPA policy is posted on the website at www.fontbonne.edu. Search under FERPA.
Please return this form to the Registrar Office located in Ryan Hall, room 205.
Registrar Office
6800 Wydown Blvd; Saint Louis, MO 63105 | Phone: (314)
889-1421 | Fax: (314) 889-1487 | registraroffice@fontbonne.edu
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