Student Authorization to Release Education Records to a Third Party

Student’s Name:  ____________________________________________________________

Item(s) of information to be released:  _____________________________________________

__________________________________________________________________________

Purpose(s) for which the education records may be disclosed (i.e., admission, employment, tuition payment or reimbursement, etc.):

__________________________________________________________________________

The information may only be released to the following person(s) or organization(s):

__________________________________________________________________________

__________________________________________________________________________

I hereby grant authorization to The Catholic University of America to release my above-referenced education records to the party or parties listed on this form. I understand that I am entitled to a copy of the records so disclosed upon request.

 

________________________________________________    ________________________
Student’s Signature                                                                       Date

Please return this form to the Registrar's Office, Room 10 in McMahon Hall.

5/23/00 web/ferpa/release1
Source: 34 C.F.R. § 99.30