FERPA (Family Educational Rights & Privacy Act)

Information Release Consent Form

8435 NE Glisan Street | Portland

What is the Purpose of this form?

The Family Educational Rights & Privacy Act of 1974 as amended, and more commonly known as the Buckley Amendment and contained in the Code of Federal Regulations (34 CFR 99, subpart D99.30), requires a written and dated consent of a student before disclosing personally identifiable information from the student's educational records to a third party.

STUDENT INFORMATION

FIRST NAME:	LAST NAME
STUDENT ID: Please fill in the whole Student ID, with the "P"

AUTHORIZATION FOR DISCLOSURE*

I authorize Multnomah University to release information as indicated by the following (check any that apply):

All College Records

You authorize all information, so the other boxes do not need to be checked as well. Please note: Records for Counseling or Pastoral Care are considered confidential records and are not covered under FERPA rules. A separate release form must be obtained from these departments.

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 your application of financial aid file.

All Student Account Records

Records include amount for tuition and fees, sources of payment for tuition and fees, refund information, records hold information, financial aid repayments, and any other of your accounts receivable information contained in students account records.

All Academic/Transcript Records

Records include transcripts, admissions and registration information, and your schedule documentation contained in the academic records.

All Student Development Records

Information may include wellness, class participation, course grade information, student status, any University care efforts on your behalf, University housing information and/or any information that may contribute positively to your wellness or student success.

Disability Records

Records include your academic accommodations and health information pertaining to disability status.

These individuals will need to supply your name and identifying information before information will be released. With few exceptions, we cannot communicate with non-MU personnel that are not listed on this form.

Person 1

Person 1 First Name

Person 1 Last Name

Person 1 Email

Relationship

Person 2

Person 2 First Name

Person 2 Last Name

Person 2 Email

Relationship

Person 3

Person 3 First Name

Person 3 Last Name

Person 3 Email

Relationship

STUDENT SIGNATURE

I understand that my decision for the release (or non-release) of student records is voluntary and will be valid while I am a student at Multnomah University. I understand that I must complete a new form to add or remove anyone from the list above. I affirm that I have carefully read the foregoing authorization and that I fully understand the meaning and intent of this document. I affirm that I have signed this authorization voluntarily.

STUDENT SIGNATURE

DATE

Hidden fields

Student (Record Type)

Constituent (Record Type)

Relationship to you

Household (Record Type)

Organization (Record Type)

If you have questions, please contact the registrar's office at 503.251.5370

Contact Information