Registrar’s Office
3050 Martin Luther King, Jr. Drive Shreveport, LA 71107
Phone: 318-670-9229 Fax: 318-670-6344
Student FERPA Release Form
Student’s Name _________________________________________ SUSLA ID# ____________________
It is the policy of Southern University at Shreveport (SUSLA), in accordance with the Family Educational Rights and
Privacy Act (FERPA), to withhold personally identifiable information contained in our students’ educational records unless
the student has consented to disclosure or FERPA allows disclosure. Directory information, such as name and address, may
be disclosed to the public upon request. However, private information, such as grades, class schedules, the student’s
account, and financial aid awards may not be released without expressed consent from the student.
I give permission for the following person(s) to have access to my educational records.
Persons to whom information may be released:
Name: ___________________________ Relationship: _________________ Release to Cancel Release
What identifiable number must this person know in order to release information by phone? __________________
Name: ___________________________ Relationship: _________________ Release to Cancel Release
What identifiable number must this person know in order to release information by phone? __________________
Name: ___________________________ Relationship: _________________ Release to Cancel Release
What identifiable number must this person know in order to release information by phone? __________________
Please initial all that apply:
_______ All Financial Records in the Student Accounts Office _______ All Financial Aid Information
_______ Other _______________________________________ _______ All Academic Records
I acknowledge by my signature that I understand that, although I am not required to release my records, I am giving my
consent to release the designated information to the person(s) named below. I understand that this release will remain in
effect unless I revoke such consent in writing and the revocation is received and processed by Southern University at
Shreveport.
_______ I DO NOT give permission to discuss my educational records. I am an independent student.
Student’s Signature: ______________________________________________ Date: __________________
This authorization will remain in effect as long as the student remains in continuous enrollment at SUSLA. Should the student’s dependency status
change during his or her enrollment period, it will be the responsibility of the student to notify the Registrar’s Office of his or her change in status.
Return this completed to the address above or to the Registrar’s Office located in the Leonard C. Barnes Administration Building, 1
st
Floor.
RO: Student FERPA Release Form:LR/12-13
Copy – Registrar’s Office Copy – Financial Aid Copy – Student Accounts
