TO: Special Needs Students
FROM: Karen DeGrange, Director International Student Services and Special Programs
RE: FERPA Release Form
By providing the information requested in this memo and returning it to Karen DeGrange
(current Disability Services Coordinator), I hereby agree to allow Karen DeGrange to
have conversations with my parents (or guardians as specified below) and release any
information from any discussions I have with Ms. DeGrange. This covers all the time
that I am enrolled as a student at Rose-Hulman Institute of Technology, or until I provide
a statement in writing to cancel my parents’ or guardians’ access to information from my
conversations with the Disability Services Coordinator.
(FERPA: Family Educational Rights and Privacy Act)
NAME: ____________________________________________________________
(Print)
SIGNATURE: _______________________________________________________
DATE: _____________________________________________________________
PARENT NAME/S:
(Print)
_______________________________________________________
Relationship:
_______________________________________________________
Relationship:
GUARDIAN: ______________________________________________________
(If parents are deceased or are not legal guardians)
Relationship: