Student Consent to Release Education Records

The Family Educational Rights and Privacy Act of 1974 (FERPA) affords certain rights to students concerning the privacy of, and access to, their education records. A student’s education records are maintained as confidential by Lees-McRae College and will not be released to a third party without the student’s prior written consent. A student may grant permission to authorized personnel of the college to release some or all of that student’s education records by completing this authorization and consent form.

This authorization will remain active for the duration of the student’s enrollment at Lees-McRae College. Any changes must be submitted in writing to the Office of the Registrar.

Student name:*

First Name

Last Name

Starting Semester*

Ex. Spring 2019

Please select one of the following:*

I hereby consent and authorize Lees-McRae College to release ALL educational records upon the requests of the person(s) identified below. I hereby consent and authorize Lees-McRae College to release the following records selected below upon the requests of the person(s) also identified below. Authorization to release information NOT granted

Check applicable records:*

Academic Records (includes transcripts, grade reports, advising records, academic progress, enrollment status) Financial Aid Records (includes awards, grants, loans, scholarships, eligibility, financial aid academic progress status) Student Account and Billing Records (includes billing statements, charges, credits, payments, past due amounts, collection activity) Student Affairs Records (includes housing, conduct/disciplinary records)

The person(s) authorized to receive these records is/are:

Name:

First Name

Last Name

Relationship to student:

Name:

First Name

Last Name

Relationship to student:

Name:

First Name

Last Name

Relationship to student:

If you choose not to permit your parents/guardian access to your records, the college can still provide information to them if you were considered financially dependent during the most recent tax year.

I understand that (1) I have the right not to consent to the release of my education records, (2) I have the right to inspect any written records released pursuant to this Consent, and (3) I have the right to revoke this consent at any time by submitting a written revocation to the Registrar.

Signature*

[clear]

Use your mouse or finger to draw your signature above

Date:*