FERPA One Time Use Form Page 1 of 2 Notary Required

Family Educational Rights and Privacy Act Release
One Time Use Form – Notary Required
Please print:
Student Name: ________________________________________________________________________
Last
First
Middle
Address: _____________________________________________________________________________
Street
_____________________________________________________________________________
City
Phone:
-
Student ID:
F
State
-
Zip
ext.
Date of Birth:
Month
Day
Year
The Family Educational Rights and Privacy Act (FERPA) is a Federal law that protects the privacy of
student education records. By signing on page 2, I understand that (1) I have the right not to consent to
the release or disclosure of my education records; (2) I have the right to inspect and review such records
upon request; and (3) this consent to release or disclose shall remain in effect for this one request only
or sooner, if revoked by me, in writing, and delivered to the person at the office named below. Any
disclosure of information made by Fairmont State University prior to expiration or receipt of revocation
is not affected by expiration or revocation. I further understand that in order for Fairmont State
University to release information to the recipient named below, this release must be signed.
1. FSU OFFICIAL/OFFICE WHICH MAY RELEASE EDUCATION RECORDS:
University Official(s)/Offices: __________________________________________________
__________________________________________________________________________
2. DESCRIPTION OF THE EDUCATION RECORDS WHICH MAY BE DISCLOSED:
__________________________________________________________________________
__________________________________________________________________________
3. RECIPIENT OF EDUCATION RECORDS:
Person/Entity Receiving Records: _______________________________________________
Address 1: _________________________________________________________________
Address 2: _________________________________________________________________
City, State: ____________________________________________ Zip: _______________
Phone: ____________________________________________________________________
Student Assigned Four (4) Digit FERPA Code:
Submit this Form to the Office Identified in Section 1.
This Form is NOT valid Without Both the Student Signature and Notary on Page 2.
FERPA One Time Use Form
Notary Required
Page 1 of 2
Family Educational Rights and Privacy Act Release
I, the undersigned, have read and reviewed Page 1 of this document and expressly authorize the
official/office identified in Section 1 to release my education records which are identified in Section 2 to
the person/entity identified in Section 3. (Sections 1, 2 and 3 are located on Page 1 of this Form)
_______________________________________________
Student Signature
_______________________
Date
STATE OF ___________________,
COUNTY OF _______________________________, to wit:
The foregoing instrument was acknowledged before me this _________ day of
____________________, 20_______ by _______________________________.
My commission expires: __________________________________________.
___________________________________
Notary Public Signature
For Fairmont State University Use Only:
Received by: ___________________________________________________________
FERPA One Time Use Form
Notary Required
Date ___________________________
Page 2 of 2