Family Educational Rights & Privacy Act – FERPA – Release of Information

Name

First Middle Last

Last 4 digits of SS #

The Family Educational Rights and Privacy Act (FERPA) is a federal law that protects the privacy of student education records. This applies to all schools that receive funds under an applicable program of the U.S. Department of Education. FERPA gives parents, legal guardians or other designees certain rights with respect to education records.

I give permission for the following information to be released to the individuals listed below.

Individual 1: Name

First Last

Individual 1: Relationship

Individual 1: Date of Birth

Individual 1: Last 4 digits of SS #

1: Would you like to include another to whom information indicated above can be released?

Individual 2: Name

First Last

Individual 2: Relationship

Individual 2: Date of Birth

Individual 2: Last 4 digits of SS #

2: Would you like to include another to whom information indicated above can be released?

Individual 3: Name

First Last

Individual 3: Relationship

Individual 3: Date of Birth

Individual 3: Last 4 digits of SS #