Revised 9/18/2018
Family Educational Rights and Privacy Act of 1974, 34 CFR Part 99
Instructions for completing this form:
1. The form must be fully completed and signed by the student. Records cannot be released if any section of this
form is not filled out entirely.
2. Completed forms should be submitted to the Office of the Registrar located in Keeny Hall. Questions about this
form may be directed to the Office of the Registrar at (318) 257-2176.
Students Name (First, Middle, Last)
The Family Educational Rights and Privacy Act (FERPA) affords certain rights to students concerning the privacy of, and
access to, their education records. Students may choose to complete and submit this form to the Registrar, allowing the
release of their education records to specified third parties. For additional information, visit Louisiana Tech’s FERPA
Information page at or the U.S. Dept. of Education’s website at
SECTION A. Academic records to be release (check selection):
All Student Academic Records
Cancel/Revoke access and/or release of academic records
SECTION B. Person(s) to whom access to academic records may be provided
First Name: Last Name:
Cell Phone Number: Home Number:____________________________
Email Address: Relationship:
First Name: Last Name:
Cell Phone Number: Home Number:____________________________
Email Address: Relationship:
Section C. Duration of release (initial each statement):
FERPA Release Authorization is valid for one (1) academic year
______ I acknowledge that I have read and reviewed my rights under the Family Educational Rights and Privacy
Act (FERPA) as listed on the back of this form.
I hereby grant permission to Louisiana Tech University to provide my academic records, and/or to discuss my academic
performance as identified above. I also understand this authorization is valid for one (1) academic year and may be
canceled at any time.
Student's Signature Date
click to sign
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The Family Educational Rights and Privacy Act of 1974, 34 CFR Part 99 (as amended) is a federal law that
provides guidelines for educational institutions regarding protection and release of student education record
information. FERPA provides Louisiana Tech students with the following rights with respect to their education
1. The right to inspect and review the student’s education records within 45 days of the day
Louisiana Tech University receives a written request for access.
Students are required to submit a signed request to the University Registrar identifying the education
records they wish to inspect. The Registrar will make arrangements for access and notify the student of the
time and place where the student may review his/her education records.
2. The right to request Louisiana Tech University to amend that part of the student’s education records
that the student believes is inaccurate or misleading.
The student will provide the Registrar with a written statement clearly identifying the part of the record
he/she wants changed and why it is inaccurate or misleading. Procedures to be used for review and appeal
are on file in the Registrar’s Office.
3. The right to consent to disclosures of personally identifiable information contained in the
student’s education records, except to the extent that FERPA authorizes disclosure without consent.
Exceptions, which permit disclosures without consent, include disclosure to school officials with legitimate
educational interests and, upon request, disclosure without consent to officials of another school in which
a student seeks or intends to enroll. A school official has a legitimate educational interest if the official
needs to review an education record in order to fulfill his or her professional responsibility.
4. The right to file a complaint with the U.S. Department of Education concerning alleged
failures by Louisiana Tech to comply with the requirements of FERPA. The address of the office
that administers FERPA is Family Policy Compliance Office, U.S. Department of Education, 600
Independence Avenue, SW, Washington, DC 20202-4605.