Student Consent to Release Information
Florissant Valley
Student Last Name ____________________________________ First Name ____________________________ MI ______
Date of Birth (mm/dd/yy) __________________ Social Security No. ____________________________
St. Louis Community College shall follow all applicable state and federal laws, rules and regulations that apply to student records.
Any past or present student’s cumulative record as maintained by the College is protected by the Family Education Rights and Privacy
Act (FERPA) and will not be released outside of the regulations without written consent of the student or upon the lawful subpoena
or other order of a court of competent jurisdiction. In order for St. Louis Community College to receive your consent, please read
the information below and authorize this form with your initials and signature.
Student information that St. Louis Community College is seeking your consent to release:
• Name, address and phone number
• Date of birth
• Last high school attended
• Transcript of grades
• Verification of attendance
• Test scores and program progress information
• Date of graduation
RELEASE TO:
q
I hereby authorize my school district to release information to St. Louis Community College and for St. Louis Community
College to release information to my school district. I authorize St. Louis Community College to biannually release information
to the Gateway to College National Network for the purpose of studying program and instruction improvement. Additionally,
I authorize St. Louis Community College to release information to the specific parties identified below.
q Parent/Guardian/Support Person
Name _____________________________________ Relationship __________________ Phone No. __________________
q Other (Students, please add names of agency case managers who are supporting your success.)
Name _______________________________ Agency (if applicable) ___________________ Phone No. ________________
Street/P.O. Address _____________________________ City __________________ State ______ Zip Code ___________
To indicate that you understand that all of the information above will be released, please initial here: _________
Student Signature ____________________________________________
If under the age of 18, parent signature required ____________________________________________
3400 Pershall Road • St. Louis, MO 63135-1408
St. Louis Community College is an equal opportunity/affirmative action institution.