Fillable Student-consent-to-release-edu-records - release form

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Student-consent-to-release-edu-records - release form

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OUR LADY OF THE LAKE UNIVERSITY
STUDENT CONSENT TO RELEASE EDUCATIONAL RECORDS
N
ote: Students are not required to complete this form; however, not doing so will prevent parents
and/or guardians from being informed on matters related to the student’s education.
In compliance with the Family Educational Rights and Privacy Act (FERPA), OUR LADY OF THE LAKE
UNIVERSITY cannot, except in certain limited situations, release a student’s education record to any
person other than the student without a written release from the student.
Student’s Name:_________________________________________________________________________________
Middle Last First
Student’s ID#:__________________
I hereby give my voluntary, written consent for OUR LADY OF THE LAKE UNIVERSITY to release my education
records upon request to the person listed below. (For purposes of this consent form, your education record includes
student account/financial, financial aid, campus life, grades and related academic information.)
_
______________________________ ____________________________
Date Student’s Signature
PERSONS TO WHOM I AUTHORIZE DISCLOSURE: (please print legibly)
#1-AUTHORIZED PERSON’S NAME
(Last, First, Middle)
Relationship to Student Authorized Person’s Date of Birth and La
(Last, First, Middle)
Relationship to Student
_____________________________________________________
Authorized Person’s Date of Birth and Last 4 digits of SS#
(Required for Identity purposes)
#2-AUTHORIZED PERSON’S NAME
(Last, First, Middle)
_____________________________________________________
Authorized Person’s Date of Birth and Last 4 digits of SS#
Relationship to Student
(Required for Identity purposes)
#3
-
AUTHORIZED PERSON
’
SNAME
st 4 digits of SS#
(Required for Identity purposes)
If you wish to list additional persons, please write their information on the back of this form.
This form may be faxed, mailed or hand carried to:
Our Lady of the Lake University
Registrar’s Office
411 S.W. 24
th
St.
San Antonio, TX 78207-4689
Phone: (210) 431-3959
Fax: (210) 436-2314
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Student-consent-to-release-edu-records - release form

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Completed 1 December 2019

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