AUTHORIZATION TO DISCLOSE INFORMATION
(Family Educational Rights and Privacy Act)
The Family Educational Rights and Privacy Act (FERPA) of 1974, as amended, provides for the confidentiality of student education records. Institutions may not disclose information about students nor permit inspection of their records without their permission unless such action is covered by certain exceptions as stipulated in the Act.
THIS AUTHORIZATION MAY BE REVOKED AT ANY TIME.
Name of Student: ____________________________________ Student Number: _____________________________
I, ________________________________, allow Ferris State University Administrators,
Faculty and Staff to speak with or
(name of student or parent)
(describe education records)
(name of individual/party/parties to speak to or release records to)
for the purpose of _______________________________________________________________________________
(describe the reason for the disclosure)
I understand further that (1) I have the right not to consent to the release of my education 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 Ferris State University, but that any such revocation shall not affect disclosure previously made by Ferris State University prior to the receipt of any such written revocation.
Date Student’s Signature
Date Parent’s Signature if Student Under 18
Please return this form to: