Student Information Release Authorization

Directions
In compliance with the Federal Family Education Rights and Privacy Act of 1974 and the Regents’ Policy on Access to and Release of Student Education Records, the University is generally prohibited from providing information from your student records to a third party.
You may, at your discretion, grant the University permission to release information about your student records to a third party. You must complete a separate form for each third party to whom you grant access to your student information. The specified information will be made available only if requested by the authorized third party or if you request that we provide it to them. The University does not automatically send information to a third party.

Section A. Student Information

Name (last, first, middle initial)

Student ID number

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Day Time Phone Number

Section B. Third party designee

Name (last, first, middle initial)

Day Time Phone Number

Address

City/Town

State/Province

ZIP/Postal Code

Relationship to student

Email Address

Section C. Information to be released

I authorize the Office of the Vice Chancellor for Student Affairs to disclose information to the above party.

Information to be released:

Student life information

Academic success and progress information

Financial information

Student records on progress in addressing health and wellness issues (not actual medical records)

Student behavior/judicial information and follow-up

All of the above

Other

If other

This release is in effect from the date of signature until

Section D. Certification

I authorize the above third party, named in Section B, to access the above indicated student information.

I understand that I can cancel this release at any time by notifying the Office of the Vice Chancellor for Student Affairs in writing and that my cancellation will take effect when this office receives my written notice.

Signature of Student

Sign above

Date