UJ Form - FERPA Form

Student Name*

Student ID #

Birthday Date*

In accordance with the Family Educational Rights and Privacy Act of 1974 (FERPA), the undersigned student hereby permits the University of Jamestown to disclose the information specified below to the following individual(s):

Name*

Relationship

Email

Phone

Name

Relationship

Email

Phone

Name

Relationship

Email

Phone

Check the box(es) below to indicate which records you wish to make available:*

All Financial Aid Records (records include: status of file, award and disbursement of funds information, Satisfactory Academic Progress status, income information, and any other information contained in the application or financial aid file).
All Academic/Transcript Records (records include: transcripts, admission and registration information, schedules, and Satisfactory Academic Progress documentation contained in the academic records).
All Student Account Records (records include: amount for tuition and fees, sources of payment for tuition and fees, refund information, records hold information, and any other accounts receivable information contained in student account records).
Instructor/Classroom Records (records include: attendance, progress reports, test and homework scores if available. Please note: instructors are not required to take attendance or provide progress reports, and retain only those records which make up the final grade. FERPA pertains to the release of records. Instructors are not required to have conversations about progress with anyone other than the student).
All Student Affairs Records (records include: student conduct, incident, and outcomes reports).
Other (Please Specify Below)

Please list other records you wish to make available.

Upon submitting this form, you agree that you are the above named student, that submission represents your written signature, and that this authorization will remain in effect from the date it is executed until revoked by you, in writing, and delivered to the Registrar’s Office.*

Upon submitting this form, I attest that I am the above named student, that submission represents my written signature, and that this authorization will remain in effect from the date it is executed until revoked by me, in writing, and delivered to the Registrar’s Office.

Date*