4700 Research Way
Lakeland, FL 33805
Student Information Release Authorization (FERPA Compliance)
In compliance with the federal Family Educational Rights and Privacy Act of 1974 and University policies on access to and
release of Student Education Records, Florida Polytechnic University is prohibited from providing certain information from
your student records to a third party, such as information on grades, billing, tuition and fees assessments, financial aid
(including scholarships, grants, work study, or loan amounts) and other student record information. This restriction applies
to, but is not limited, to your parents, your spouse, or a sponsor.
You may, at your discretion, grant the University permission to release information about your student record to a third
party by submitting a completed Student Information Release Authorization. A separate form is required for each third
party to whom you grant access to information on your student records. The specified information will be made available
only if requested by the authorized third party. The University does not automatically send information to a third party.
The student authorizing the release of their educational records must sign and present this form to the Registrar’s Office
with a valid photo ID to verify authenticity of this release. Please note that your authorization to release information has
no expiration date; however, you may revoke your authorization at any time by completing this same form and returning
it to the Registrar’s Office. This form allows third parties to access student record information from any Florida Poly
campus. However, it is University policy not to release certain aspects of student records (e.g., grades, GPA) over the
phone or via email due to limited security of these channels. Authentication by a passphrase will be required of a caller
before release of this information by telephone. Due to the lack of security of email, information will not be released and
you will be notified to change your passphrase if someone has included it in an unencrypted email.
NOTE: For the third-party designee you name on this form, this release overrides all FERPA directory suppression
information that you have set up in your student record. This means that the University will release information to the
specified individual even if you have generally prohibited the disclosure of directory information in your student record.
Step 1: Student Acknowledgement (Please review FERPA Compliance and sign if in agreement)
I, the undersigned student, acknowledge the information listed above and agree to the terms of the Student
Information Release Authorization.
Student Signature: ________________________________________________ Date: ___________________
Student’s Information (please print legibly):
___________________________________________________________ ______________________________
Student’s Last Name, First Name, Middle Initial Student ID
_______________________________________________ __________________________________________
Email Address Phone Number
Step 2: Identify Passphrase (will be used to authenticate identify)
When an authorized third-party designee (next page) is asked to authenticate their identity, they must provide the
passphrase. You, the student, may update this passphrase at any time by completing a new form.
Passphrase: There is a 30 character limit. Foul language, crude references, or inappropriate phrases will not be accepted.
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4700 Research Way
Lakeland, FL 33805
Step 3: Identify Third-Party Designee
_______________________________________________________________ ______________________________
Name (Last, First, Middle Initial) Relation
Step 4: Identify Information to be Released (Please initial next to each area you wish to authorize)
Information Allowed to be Released (Initial next to each area you wish to authorize)
______ Academic records maintained by the Office of the University Registrar (To include grades, GPA,
demographic, registration, academic status, and/or enrollment information.)
______ Student Account and Financial Aid records (Records include billing statements, charges, credits, payments, past
due amounts, collection activity, financial aid awards, disbursements, FAFSA, and/or financial aid satisfactory
academic progress reports.)
______ Conduct records (Please Note: Conduct items may be discussed with the authorized individuals, but not copied
and/or disseminated as a physical or electronic release to anyone other than the student of record.)
______ Other (Must Specify) ___________________________________________________
Additional information may be temporarily released by completing the Limited Release of Educational
Records Request form. For example:
Information specific to a completed or in progress course (i.e. letters of reference or other academic items at
the discretion of the instructor)
Name and contact information for students who have requested a FERPA block on their records (A FERPA block
prohibits the University from acknowledging you are a student to 3
Please Note: Records for Counseling and services for Students with Disabilities will require a separate release form
that can be obtained from these departments.
If Applicable: Complete to Revoke Access (Complete Step 1 and Step 3 only)
I hereby revoke my previous release of any and all information to the above listed designee.
_________________________________________________________ ______________________________
Student’s Signature Date
Please Note: To reinstate revoked access or modify existing access, a new release form must be submitted.
Administrative Use Only:
Student ID verified by: __________________________________ Date: _______________________
Processed by __________________________________________ Date: _______________________
(If received by department other than Registrar’s Office)
Submit to Registrar’s Office for final processing
Processed by Registrar Staff ______________________________ Date: _______________________
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