Consent for Release of Information · FERPA Release Form
Student Name
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First Name
Middle Name
Last Name
Suffix
Date of Birth
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Month
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Day
Year
Student ID Number
7-digit Student ID Number
Email
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example@my.wilsoncc.edu
In accordance with the Family Educational Rights and Privacy Act of 1974 (FERPA), the undersigned student hereby permits Wilson Community College to release the information specified below to the following individual(s) or agency(ies):
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Explanation of types of records:
All Financial Aid Records:
records such as, but not limited to, status of file, award and disbursement of funds information, Satisfactory Academic Progress status, income information, and any other information contained in the application or financial aid file.
All Academic/Transcript Records:
records such as, but not limited to, transcripts, admission and registration information, schedule documentation contained in the academic records.
All Student Account Records:
records such as, but not limited to, amount for tuition and fees, sources of payment for tuition and fees, refund information, records hold information as it relates to parking tickets, library fines, financial aid repayments and any other accounts receivable information contained in student account records.
Instructor/Classroom Records:
records such as, but not limited to, attendance, progress reports, and test and homework scores if available.
(Please note: FERPA pertains to the release of records. Instructors are not required to have conversations about progress with anyone other than the student.)
Check the box(es) below to indicate which records you wish to make available:
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All Financial Aid Records
All Academic/Transcript Records
All Student Account Records
Instructor/Classroom Records
All College Records
Letter of Reference (Additional information needed)
Other (Additional information needed)
Letter of Reference: I request that the entity/individual named below may serve as a reference for me.
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Other: Please specify below.
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Please note: Records for Counseling and services for Students with Disabilities are considered medical records and are not covered under FERPA rules. A separate release form must be obtained from these departments.
Student Signature
Click here to sign
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Date of Submission
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Month
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Day
Year
Submit
Should be Empty: