Marshall University Family Educational Rights and Privacy Act Authorization to Release Information Form

Marshall University - Family Educational Rights and Privacy Act Authorization to Release Information

This form authorizes Marshall University to release educational records to the person or entity identified.

Please use this form to consent to authorize Marshall University to release your educational records to different individuals and/or entity(ies).

Information about You

Your Name(Required)

First Middle Last

Student ID Number(Required)

Provide your Marshall University ID Number.

Preferred Name / Pronouns(Required)

List your preferred name and pronouns.

Date of Birth(Required)

Preferred Method of Contact

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Family Educational Rights and Privacy Act (FERPA)

The Family Educational Rights and Privacy Act (FERPA) protects student confidentiality by placing certain restrictions on the disclosure of information contained in a student’s education records. By signing this form, you agree that Marshall University personnel may provide information from your education records as indicated below. You further acknowledge that: (1) You have the right not to consent to the release of your education records; and (2) this consent shall remain in effect until revoked by you, in writing, and delivered to Marshall University, but that any such revocation shall not affect disclosures made prior to the receipt of any such written revocation.

Please identify specific records, types of records, or indicate “all records”:(Required)

The Person/Entity Receiving Records:(Required)

Address of Person/Entity Receiving Records(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Scope of Release

I hereby authorize Marshall University to release personal information and written records to the above listed person/entity from my educational records related to the following: 1) Any Title IX or related student disciplinary proceeding for sexual, interpersonal, or other acts of violence; 2) Any criminal conviction for sexual, interpersonal, or other acts of violence; or 3) Any Title IX or student disciplinary proceeding for sexual, interpersonal, or other acts of violence that was pending when I left Marshall University. Additionally, I authorize Marshall University to conduct any other investigation(s) it deems necessary to comply with policies or any federal or state law. This authorization includes, but is not limited to, conducting a criminal background check.

Student Responsibilities and Consent for Disclosure

I understand that: 1) I have the right to revoke this consent, in writing, at any time except to the extent that action has already been taken upon this release. 2) I will not be contacted after an inquiry is made or information is released by/to Marshall University, 3) I have completed this disclosure form myself, and I understand what it says and agree to its terms.

Your Name(Required)

First Middle Last

Thank you for taking the time to fill out the Marshall University - Family Educational Rights and Privacy Act Authorization to Release Information Form.