FERPA Information Release Form

FERPA Request for Records Release, Records Inspection & Directory Opt-Out

Student Name:*

First Name

Middle Name

Last Name

Student CWID:*

Student Social Security Number:*

Release Information or Cancel Release:*

Release information to the third party that I list below Cancel my authorization to release information to the third party that I list below

Choose One:*

This FERPA Release is for a Person This FERPA Release is for a Group/Organization

Name of Person Referenced Above:*

First Name

Last Name

Name of Group/Organization Referenced Above:*

Choose One

Relationship to Student:*

Address of Third Party Listed Above:

Address Line 1

Address Line 2

City

State

ZIP Code

I authorize (or cancel) the items checked below:*

Grades/GPA, demographic, registration, student ID number, and academic status progress, enrollment information Financial Aid awards, application data, disbursements, eligibility, and/or financial aid satisfactory academic progress status Billing statements, charges, credits, payments, past due amounts, and/or collection activity

Other:

Other

Additional request

Withhold my Directory Information An inspection of my academic records.

Other:

Please select one or more options

If Other, Please Specify:

Today's Date:*

Signature (Full Name):*

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