If you have submitted this form to the college previously, you need to submit another copy only if you wish to change the information previously
submitted or to establish a new FERPA password. This form may be submitted to registrar@hvcc.edu as an attachment to a message sent from your
HVCC student e-mail account. If your signature has been notarized, the form will be processed accordingly. Otherwise, a member of the Registrar’s
Office staff will arrange a Zoom session with you to authenticate your identity. Please be prepared to show picture ID during the Zoom session. You
must have access to a device with a camera in order to prove your identity via Zoom.
I understand that, in order for Hudson Valley Community College to disclose personally identifiable information from
my educational records to a third party, I must provide consent. I further understand that, for any such disclosure over
the phone, even to myself, the college must authenticate the caller using the FERPA password I establish below.
I understand that I am not required to sign and return this form if I do not wish consent to be given or if I do not wish to
receive information over the phone.
The below FERPA password must be provided, either by myself or any named individual below, when making a tele-
phone inquiry.
FERPA Password ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ (The FERPA password must be no more than 10 characters and cannot be
your date of birth, any part of your student ID # or SSN, or your WIReD password).
I am giving consent to either:
□ Disclose any and all education records, which includes all items in the box below, OR
□ The following records/information may or may not be disclosed as indicated in the box below:
Disclose Do not disclose Disclose Do not disclose
Attendance records Permission to speak w/advisor
Billing/Student Account Permission to speak w/instructor(s)
information Schedule
Financial Aid information Other – please specify
Grades ___________________________
Graduation information ___________________________
The purpose of the disclosure is (check one or both):
□ to obtain information about my student record via telephone
□ to authorize individuals named below to obtain information about my student record
The party or class of parties to whom a disclosure may be made is:
Name(s):
Relationship: □ parent □ guardian □ spouse □ sibling □ other _______________________________________________
(This does not include consent for information to be given to another college.)
________________________________________________ ____________________ ____________________
Student Name (please print) Date of Birth Date
Student ID Number
STATE OF NEW YORK :
:ss.:
COUNTY OF :
On the _________ day of _______________ in the year _______ before me, the undersigned, personally appeared
__________________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the
individual(s) whose name(s) is(are) subscribed to the within instrument and acknowledged to me that he/she/they executed the
same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon
behalf of which the individual(s) acted, executed the instrument.
Notary Public
FERPA WAIVER ● AUTHENTICATION FORM
Office Use Only: verified ID
Initials Date
Hudson Valley Community College ● 80 Vandenburgh Avenue ● Troy, NY 12180-6096 ● (518) 629-4574
H
For use by a notary public.
