StudentPermissionFormReleaseofConfidentialInformationfromtheStudentEducationRecord

IncompliancewiththeFamilyEducationalRightsandPrivacyActof1974(FERPA),thedisclosureofinformationfromastudentseducationalrecordisconsideredconfidentialandwillnotbereleased,withcertainexceptions,withoutthestudentswrittenpermission.InaccordancewithFERPA,theUniversityofColoradoatBoulderwilldisclosetoaparent(s),spouse,otherfamilymember(s),orthirdparty(s)informationfromthestudenteducationrecordprovidedtheUniversityhasonafilewrittenconsentfromthestudent.PleasecompletethefollowinginformationbelowandreturntotheOfficeoftheRegistrar,Regent105.

_________________________________________________ ______________________________________(StudentName) (StudentID)

1. SpecificRecordsthatmaybedisclosed: TranscriptRequest Grades StudentFinancial/BillingInformation HoldsorSuspensions(AcademicorFinancial) FinancialAid(FinancialAidInformationislimitedperGrammLeachBlileyActof1999) GPA CourseSchedule HousingInformation AcademicAdvising TuitionClassification/Residency(*mayincludedetailedfinancial,creditcard,banking,IRSTaxforms,andotherpersonallysensitiveinformation) Alltheabove Otherspecificinformationfrommyeducationalrecord(canbedatespecific):______________________ _____________________________________________________________________________________ 2. Youmuststatethepurposeofthedisclosure: Toprovidetheinformationtotheperson(s)indicated: Other:_______________________________________________________________________________ _____________________________________________________________________________________3. Name(s)towhomtheinformationmaybereleased(pleaseprintclearly):_____________________________ _____________________________ __________________________________________________________ _____________________________ __________________________________________________________ _____________________________ _____________________________4. Youmustestablishapasswordwiththeindividualslistedin#3beforewecanprovideaccesstoinformationfromyourstudenteducationalrecord.

Wewillnotreleaseanyinformationfromyourrecord(otherthandirectoryinformation)unlesstheperson(s)namedaboveprovidesusthispassword.Thispasswordis:_______________________________________.

Bysigningbelow,youagreethatUniversitypersonnelmayprovidetheinformationidentifiedabovefromyoureducationrecord.Thisapprovalwillremaininyourrecord,andwillallowustoreleasetheinformationyouhaveauthorized,evenwhenyouarenolongerlistedasadependentuponyourparentsincometaxreturn,oryouhavegraduatedorlefttheUniversity,unlessyourevokethispermission.

NOTE:Evenifyoudonotsignthisform,yourparentsmayaccessyoureducationrecordsifyouarestilladependentandtheydeclareyouasadependentontheirmostrecentfederalincometaxformandyouareunder21yearsold(accordingtotheInternalRevenueCodeof1986,Section152).

_________________________________________________ ______________________________________StudentSignature Date

*Students,youmustreturnthisforminpersonwithaPhotoIDtotheOfficeoftheRegistrar,RegentAdministrativeCenterRoom105.