The Family Educational Rights and Privacy Act (FERPA) of 1974 prohibits Merced College from releasing certain personally
identifiable information from a student’s educational records to a third party (e.g. parent, spouse, etc.) without the student’s
explicit written consent. This form serves as written consent when properly completed.
Instructions: Complete this form with all applicable information. The student MUST be present to sign this form in front of an
authorized Merced College staff member. (Admissions and Records, Student Fees)
, ,
(Print student name)
(Student’s Merced College ID Number)
give consent for Merced College to disclose personally identifiable information concerning my educational records to the
individual(s) listed below. These individuals also become eligible to act on my behalf. Releasable information includes, but is not
limited to, the following: eligibility to register for classes, information on coursework completed in prior terms, transcript and
grades, academic standing, credit hours, class schedule, account balance, and other such information. Persons listed below also
will be able to initiate enrollment for future terms.
I also understand that the individuals listed below who request information in person are REQUIRED to provide picture ID when
they appear.
Merced College may release my information to the following individual(s):
Date of Birth (mm/dd/yyyy):
Phone Number: ( ) -
Date of Birth (mm/dd/yyyy):
Phone Number: ( ) -
I certify this request was signed voluntarily and I understand that it will remain in effect for one year from
the date of the student’s signature below. If I wish to revoke this Authorization I must do so in writing.
Student Signature: __ Date: ____ ___
Office Use Only:
MC Staff Witness Signature: ________ _ Date: ________________________________
Authorization to Release Student Information