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.