RECORDS RELEASE AUTHORIZATION FORM rev. 04/21/14

205 Sproul Hall, MC 2432
Berkeley, California 94720-2432
Tel 510.643.9069 Fax 510.643.3133
[email protected]
RECORDS RELEASE AUTHORIZATION FORM
The University of California, Berkeley has a responsibility to protect students’ and student organizations’ information,
including information pertaining to conduct files as defined by the Family Educational Rights and Privacy Act (FERPA). This
information is strictly confidential and can only be released upon the written consent of the student or student organization’s
current leadership.
The Center for Student Conduct is the office of record for all conduct files pertaining to the Berkeley Campus Code of
Student Conduct. The Center for Student Conduct will provide a scanned electronic copy of the requested file(s) to the
authorized e-mail address provided below upon request. Please allow three business days to process this request as all
documents must be redacted for identifiable information pertaining to other students.
I waive my right to confidentiality and grant officials administrating the conduct process at the University of California, Berkeley
permission to share information pertaining to my conduct record to the following party and authorized e-mail address:
Recipient’s Name: ________________________________ Relationship to you:
Authorized E-Mail:________________________________
Self
Other: __________________
Phone: ( __________ ) __________ - __________________
Content of Release:
Method of Release (please check one):
Complete conduct record
Verbal communication
Case #_____________________________________
Scanned electronic copy
Audio recording(s) associated with the above case(s)
Both verbal communication and
Hearing information and content
scanned electronic copy
I understand and confirm that I have authorized and requested to send information by electronic mail to the authorized e-mail address provided
in connection with the request of the above conduct record(s).
I acknowledge that the information requested is confidential information under the Family Educational Rights and Privacy Act (FERPA) and will
be redacted in accordance with the University of California Berkeley Disclosure of Information from Student Records Policy (rev. July 17, 2008).
I understand that the transmission of information by e-mail may not be secure and e-mail has been known to be lost, to arrive incompletely, to
arrive belatedly, to arrive with errors and/or be corrupted, or to contain viruses; and that the information will not be encrypted when it is sent.
I understand that I am primarily responsible for keeping the above person updated on information regarding my conduct case after the date signed
below, and that I or the above person will contact the Center for Student Conduct regarding future information as necessary.
I understand that my consent to receipt of this information by e-mail will remain in effect until revoked by me, and that I can revoke my consent to
this receipt at any time by contacting the Center for Student Conduct at the University of California, Berkeley.
I understand that I may authorize communication about my conduct record and case between university officials and those authorized by me by
filling out the Records Release Authorization Form and signing my name below.
Fill in this box only if you are requesting a record for a student organization:
______________________________________________ _______________________________________________
Printed Name of Student Organization
Leadership Position
______________________________________________________
Name of Authorizer (Student’s Printed Name)
______________________
SID
______________________________________________________
Signature of Authorizer
______ / ______ / ______
Date
rev. 04/21/14