FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT (FERPA) RELEASE FORM

Please choose ONE option of Release or Restrict below.

Release Information Authorization

Please Note:  Filling out a new release form will cancel any existing release of information request currently on file.

Please RELEASE my information to*:  (Ex. Parents, Employers, Health Care Professionals, State/Federal Agencies)
*List names of persons/businesses, including their relation to you, phone numbers, and/or email addresses.

Name:

Relation to you:

Phone Number:

Email Address:

Name:

Relation to you:

Phone Number:

Email Address:

Name:

Relation to you:

Phone Number:

Email Address:

Releasing specified information:

You may request specific information be released or specific persons to obtain non-directory information.  For instance, you may request the college to verify your degree to future employers, or allow the college to speak to your parents about your educational records.

If specific information may be released, please explain:

Restrict Directory Information

FERPA defines “directory information” as information contained in the education records of a student that would not generally be considered harmful or an invasion of privacy if disclosed. Typically, “directory information” includes information such as Your full name; the fact that you are or have been enrolled in the college; local and permanent address(es) and telephone number(s); email address; date and place of birth; participation of recognized activities and sports; weight and height of members of athletic teams; dates of attendance; class level; major field of study; number of credit hours (not grades or GPA); degrees and awards received; photographs; the most recent educational institution you attended; job title(s) and dates of employment for student employees who have been or are being paid from college administered funds.

Please RESTRICT the release of my directory information except for photographs*.

Please RESTRICT the release of my directory information including photographs*.

*Student photographs are occasionally published in Southwestern's college newsletter; Restricting the release of photographs expires at the end of each term.

First Name:

Last Name:

Student ID OR Social Security Number:

Please check to make sure you selected and filled out information for ONLY ONE (1) option above.  If you chose multiple options the form you submit will be void.