Consent for Release of Student Information
The Family Educational Rights and Privacy Act of 1974 (FERPA) sets forth requirements regarding
the privacy of student information. In compliance with FERPA, any information other than directory
information requires consent of the student.
I, __________________________________________Student ID_______________________________,
(Student Name/Student ID#)



Acknowledge that:
o Name_______________________________________________,
o Relationship___________________________________________ has my permission
to be present during discussions that may include my private student information.
Understand that I have no obligation whatsoever to approve the release of information.
Understand that this consent shall remain in effect until revoked by me, in writing, and
delivered to the above named person, but any such revocation shall not affect disclosures
made prior to the person’s receipt of my written revocation.
Student Signature ________________________________________
Date____________________________________________________