FERPA AUTHORIZATION FOR RELEASE OF STUDENT EDUCATION RECORDS

Pursuant to the Family Educational Rights and Privacy Act (20 U.S.C. § 1232g; 34 CFR Part 99)

1. STUDENT IDENTIFICATION

This authorization applies to the education records belonging to the following student:

Student Full Legal Name: __________
Date of Birth: __________
Student ID Number: __________
Attending Institution / School: __________

2. RELEASING INSTITUTION & DESIGNATED RECIPIENT

I hereby grant voluntary permission and authorization to __________ to release, disclose, and make accessible the designated education records to:

Designated Recipient / Party: __________

Purpose of Disclosure: This disclosure is made specifically for the purpose of __________.

3. SPECIFICATION OF EDUCATION RECORDS TO BE DISCLOSED

Under 34 CFR § 99.30, the specific records authorized for disclosure include:

• All official student education records maintained by the institution.

Time period covered by these records: From __________ to __________.

4. STATUTORY NOTICE: REDISCLOSURE PROHIBITION (34 CFR § 99.33)

Notice to Recipient: This information is disclosed under the condition that the recipient shall not permit any other party to have access to such information without the prior written consent of the student or parent/guardian, pursuant to 34 CFR § 99.33(a)(1).

5. EXPIRATION & STATUTORY RIGHT TO REVOKE (34 CFR § 99.30)

This authorization shall remain valid and in effect until __________, unless revoked earlier in writing by the signer.

Right to Revoke & Inspect Copies: Under federal law, I retain the right to revoke this authorization in writing at any time by delivering a signed revocation notice to the releasing institution. Revocation shall not affect records already disclosed prior to receipt of notice. Pursuant to 34 CFR § 99.30(d), the undersigned has the right to request a copy of the records disclosed.

6. LEGAL CAPACITY & AUTHORIZATION AFFIRMATION

By signing below, I affirm under penalty of perjury that I am either: (a) the eligible student aged 18 or older, or enrolled in a postsecondary institution; or (b) the lawful parent or legal guardian with authority to act on behalf of the minor student.

IN WITNESS WHEREOF, I have executed this FERPA Student Record Release Authorization on __________.