FERPA Consent for Release of Education Records

FERPA Consent for Release of Education Records

Purpose and Legal Basis

This form authorizes the educational agency or institution identified below to disclose personally identifiable information from a student's education records to the recipient(s) named herein, in accordance with the Family Educational Rights and Privacy Act ("FERPA"), 20 U.S.C. § 1232g, and its implementing regulations at 34 C.F.R. Part 99. Under 34 C.F.R. § 99.30, a parent or eligible student must provide signed and dated written consent that specifies the records to be disclosed, the purpose of the disclosure, and the party or class of parties to whom the disclosure may be made.

1. Institution and Student Identification

Educational Agency or Institution (School):

School Name: [________________________________]

School / District Address: [________________________________]

City, State, ZIP: [________________________________]

Records Custodian / FERPA Officer: [________________________________]

Telephone: [________________________________] Email: [________________________________]

Student:

Student Full Legal Name: [________________________________]

Date of Birth: [__/__/____]

Student ID Number: [________________________________]

Grade / Year / Program: [________________________________]

Current Address: [________________________________]

City, State, ZIP: [________________________________]

2. Rights Holder Providing Consent

Check ONE:

☐ Parent or Legal Guardian of a student who is under 18 years of age AND not enrolled in a postsecondary institution.

☐ Eligible Student (student who is 18 years of age or older, OR who is enrolled in a postsecondary institution at any age).

☐ Other Authorized Party (e.g., court-appointed guardian, person acting in place of a parent). Attach documentation of authority: [________________________________]

Printed Name of Rights Holder: [________________________________]

Relationship to Student: [________________________________]

3. Records Authorized for Release

I authorize the school to disclose the following education records (check all that apply):

☐ Transcripts, grades, and report cards

☐ Attendance records

☐ Disciplinary records (incident reports, suspensions, expulsions)

☐ Individualized Education Program (IEP) and/or Section 504 Plan, including meeting notes and prior written notices

☐ Health and immunization records maintained by the school

☐ Psychological, counseling, and social work records maintained by the school

☐ Special education evaluations, re-evaluations, and related assessments

☐ Law enforcement unit records maintained by the school (to the extent they constitute education records)

☐ Standardized test scores and academic assessments

☐ Records of prior disclosures (34 C.F.R. § 99.32)

☐ Other (describe with specificity): [________________________________]

Time period of records to be released: from [__/__/____] to [__/__/____] ☐ All records on file

4. Recipient(s) of Records

Recipient 1:

Name / Organization: [________________________________]

Individual Contact (if organization): [________________________________]

Relationship to Student / Role: [________________________________]

Mailing Address: [________________________________]

City, State, ZIP: [________________________________]

Email: [________________________________] Telephone: [________________________________]

Recipient 2 (if applicable):

Name / Organization: [________________________________]

Individual Contact (if organization): [________________________________]

Relationship to Student / Role: [________________________________]

Mailing Address: [________________________________]

City, State, ZIP: [________________________________]

Email: [________________________________] Telephone: [________________________________]

Recipient 3 (if applicable):

Name / Organization: [________________________________]

Individual Contact (if organization): [________________________________]

Relationship to Student / Role: [________________________________]

Mailing Address: [________________________________]

City, State, ZIP: [________________________________]

Email: [________________________________] Telephone: [________________________________]

5. Purpose of Disclosure

I am requesting this disclosure for the following specific purpose(s):

[________________________________]

[________________________________]

[________________________________]

6. Method of Transmission

I authorize the school to transmit the records by the following method(s):

☐ U.S. Mail (standard)

☐ U.S. Mail (certified, return receipt requested)

☐ Secure email (encrypted / password-protected)

☐ Facsimile to: [________________________________]

☐ In-person pick-up by recipient (ID required)

☐ Secure electronic portal / file transfer: [________________________________]

☐ Other: [________________________________]

7. Duration and Expiration of Consent

This consent shall remain in effect as follows (check ONE):

☐ One-time disclosure only. This consent expires upon completion of the disclosure described above.

☐ Limited duration. This consent is valid for [____] days from the date signed below.

☐ Until a specified date. This consent expires on [__/__/____].

☐ Duration of a defined matter. This consent remains in effect until: [________________________________]

If no option is selected, this consent shall be deemed a one-time authorization.

8. Right to Revoke Consent

I understand that I may revoke this consent at any time by delivering a signed, written revocation to the school's records custodian identified in Section 1. Revocation is effective upon the school's receipt and applies prospectively only; it does not affect any disclosure that the school has already made in reliance on this consent. 34 C.F.R. § 99.30.

9. Limitations on Redisclosure

I understand that, under 34 C.F.R. § 99.33, the recipient(s) named above generally may not redisclose personally identifiable information from the student's education records to any other party without additional written consent from the rights holder, except as permitted by FERPA. The school will inform recipients of this redisclosure limitation at the time of disclosure.

10. Acknowledgments

By signing below, I acknowledge and affirm that:

☐ I am the parent, legal guardian, or eligible student identified in Section 2, and I have authority to consent to this disclosure.

☐ I understand that I am not required to consent to this disclosure, and that the school generally may not condition receipt of educational services on my signing this form.

☐ I have read this form, understand its contents, and am signing it voluntarily.

☐ The information I have provided on this form is true and accurate to the best of my knowledge.

☐ I understand that the school may require verification of my identity before releasing records.

☐ I have received or been offered a copy of the records to be disclosed, upon my request, in accordance with 34 C.F.R. § 99.30(c).

11. Signature

Signature of Rights Holder: [________________________________]

Printed Name: [________________________________]

Relationship to Student: ☐ Parent ☐ Legal Guardian ☐ Eligible Student ☐ Other: [____]

Date Signed: [__/__/____]

Daytime Telephone: [________________________________]

Email: [________________________________]

Mailing Address: [________________________________]

Witness / Notary (optional, if required by institution):

Witness Signature: [________________________________]

Printed Name: [________________________________] Date: [__/__/____]

12. School Use Only

Date Consent Received: [__/__/____]

Received By (Name / Title): [________________________________]

Identity of Rights Holder Verified: ☐ Yes ☐ No

Method of Verification: ☐ Government-issued photo ID ☐ On-file signature match ☐ In-person known to staff ☐ Other: [____]

Records Released On: [__/__/____]

Released By: [________________________________]

Method of Transmission Used: [________________________________]

Disclosure Log Entry Reference (34 C.F.R. § 99.32): [________________________________]

Notes: [________________________________]

Sources and References

• Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. § 1232g — https://www.law.cornell.edu/uscode/text/20/1232g
• 34 C.F.R. § 99.30 (Prior consent for disclosure required) — https://www.ecfr.gov/current/title-34/subtitle-A/part-99/subpart-D/section-99.30
• 34 C.F.R. § 99.31 (Conditions for disclosure without consent) — https://www.ecfr.gov/current/title-34/subtitle-A/part-99/subpart-D/section-99.31
• 34 C.F.R. § 99.32 (Recordation of disclosures) — https://www.ecfr.gov/current/title-34/subtitle-A/part-99/subpart-D/section-99.32
• 34 C.F.R. § 99.33 (Limitations on redisclosure) — https://www.ecfr.gov/current/title-34/subtitle-A/part-99/subpart-D/section-99.33
• U.S. Department of Education, Student Privacy Policy Office — https://studentprivacy.ed.gov/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Have it reviewed by qualified counsel in your jurisdiction before use.