Fillable The University of Texas as Tyler Authorization for (University of Texas at Tyler)

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The University of Texas as Tyler Authorization for (University of Texas at Tyler)

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The University of Texas as Tyler
Authorization for Disclosure of Student Educational Records
The University of Texas at Tyler ▪ One-Stop Services Center, STE 230 ▪ 3900 University Blvd. ▪ Tyler, TX ▪ 75799
Updated 2/2019
Pursuant to the Family Educational Rights and Privacy Act (FERPA), I, the undersigned individual (per signature in Section E
of this form) consent to the release of information from the educational records of the individual listed under Section A of
this form. Further, I confirm that I have read, understand, and will abide by all items listed under the Notices section below.
Notices:
This form must be submitted to the address listed at the bottom of this form per the following guidelines:
o In person by the student named in Section A with a valid photo ID, or
o via mail by the student named in Section A along with a confirmation of their identity provided by a Notary Public, or
o in person by an agent of the student in conjunction with original or certified copies of legal documentation establishing
their right to act on behalf of the student with specific regard to education records
Students or agents may revoke this form in writing, subject to the submission guidelines described above.
This form grants the Recipient defined in Section B standing access to the record types designated in Section C, for the purpose(s)
defined in Section D, to be obtained either in person (pending confirmation of a valid photo ID), by email (requires student’s UT
Tyler ID number and student-created PIN be provided), or by requesting they be mailed to the address provided in Section B;
requests to send records to any other addresses will not be honored.
This consent cannot be used to access or obtain student treatment records maintained by the University Health Clinic or Student
Counseling Center.
Recipients, as defined by Section B, are granted no rights to act on behalf of the student listed in Section A in any capacity.
The University is not responsible for the subsequent uses or disclosures of records once they are released pursuant to this consent.
A. Student Information (Please print)
NAME (FIRST, MIDDLE INITIAL, LAST)
STUDENT ID NUMER
CURRENT ADDRESS (STREET/PO, APT., CITY, STATE & ZIP)
PRIMARY DAYTIME PHONE NUMBER
B. Third-Party Recipient Information (One per form; Please print)
NAME (FIRST, MIDDLE INITIAL, LAST)
RELATION TO STUDENT
CURRENT ADDRESS (STREET/PO, APT., CITY, STATE & ZIP)
PRIMARY DAYTIME PHONE NUMBER
C. Information Authorization: Check one or more boxes below to grant access to the Recipient listed above.
□ Transcripts
□ Financial Aid records
□ Other (specify below)
Other Reason:
D. Purpose of Records Release (FERPA-mandated)
□ Family communications
□ Employment
□ College admissions
□ Other (specify below)
Other Reason:
E. Authorization Certification:
STUDENT’S (OR AGENT’S) SIGNATURE
DATE
STUDENT’S (OR AGENT’S) PRINTED NAME
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The University of Texas as Tyler Authorization for (University of Texas at Tyler)

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Completed 30 August 2020

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