UNIVERSITY OF ILLINOIS AT SPRINGFIELD
Office of Records and Registration FERPA Release Form
Please complete, print (see "Print Form" button above), sign, and return this form to the Office of Records and Registration, University Hall, One
University Plaza, MS UHB 1076, Springfield, IL 62703-5407. Forms are processed on a weekly basis. Please be sure to carefully complete all
information prior to printing the document.
Last Name First Name
UIN
Records (217) 206-6709 Degree Audits (217) 206-8216 Registration (217) 206-6174 Graduation (217) 206-7730
For Office Use Only
Processed By:
Date:
Student Signature
I understand further that (1) I have the right not to consent to the release of my educational records; (2) I have the right to receive a copy of such
records upon request; (3) and that this consent shall remain in effect until revoked by me, in writing, and delivered to UIS' Office of Records and
Registration, but that any such revocation shall not affect disclosures previously made by UIS prior to the receipt of any such written revocation.
These records are being released for the purpose stated below:
Date
Signature of Parent/Guardian (required only if student is under 18) Date
Copy (distributed by the Office of Records and Registration):
Original:
Student
Permanent File
I, the undersigned, hereby authorize the University of Illinois at Springfield (UIS) to release the following educational records and information
(identify records or types of records below):
These records should be released to the following person/agency (identify name and address of person/agency to receive information):
Person/Agency
Address City State Zip Code
DateNotary Signature and Seal (contact UIS Registrar to see if required)
THIS INFORMATION IS RELEASED SUBJECT TO THE CONFIDENTIALITY PROVISIONS OF APPROPRIATE STATE AND
FEDERAL LAWS AND REGULATIONS WHICH PROHIBIT ANY FURTHER DISCLOSURE OF THIS INFORMATION WITHOUT
THE SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS, OR AS OTHERWISE PERMITTED BY SUCH
REGULATIONS.
3-06-09
