FERPA Release Form

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FERPA Release Form
By providing the information requested in this form and returning it to the Director of Disability Services,
I hereby agree to allow the Director to have conversations with my parents or guardians, as specified
below, and release any information from any discussions I have with the Director. 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 such information.
[FERPA: Family educational Rights and Privacy Act]
NAME: [print]______________________________________________________________________
SIGNATURE: _______________________________________________________________________
DATE: _____________________________________________________________________________
PARENT NAMES: [Print]
_____________________________________________________________________________________
Relationship:
_____________________________________________________________________________________
Relationship:
GUARDIAN [if parents are deceased or are not legal guardians]:
_____________________________________________________________________________________
Relationship:
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