Office of the Registrar 330 Powell Avenue, Newburgh, New York 12550 • www.msmc.edu

Ph: 845-569-3279 Fax: 845-569-3301

FERPA Release Form– Academic Records Requested by: (Student)

Release to: (Recipient(s)) ______________________________________

______________________________________ First Name

Last Name

_____________________________________________ Student ID Number

_____________________________________________ Date

RELEASE INFORMATION If you would like more information on FERPA (Family Educational Rights and Privacy Act), please contact the Registrar’s Office at (845) 569-3279

First Name (1)

Last Name

_____________________________________________ First Name (2) Last Name _____________________________________________ Organization or School (if applicable) _____________________________________________ Address _____________________________________________ City State Zip code _____________________________________________ Phone Number _____________________________________________ Relationship to Student

ACADEMIC RELEASE REQUEST: I give permission for Mount Saint Mary College to release my academic records to the recipient listed above.* The purpose of this disclosure is:_________________________________ ______________________________________________________________________________.

SIGNATURE: ______________________________Date:____________ Once this document is filed with the Registrar’s Office, it will be on file until you remove it. You may remove this release at any time by coming into our office to deactivate the form. This form must be turned in by the student only.

*Please note that Financial and Non-Academic Disciplinary records require an additional release. DEACTIVATION REQUEST: Please deactivate my FERPA Release Form. I no longer want to give access to my academic record to any of the above mentioned recipients.

SIGNATURE: ______________________________Date:____________ Release: Deactivation: Office Use Only: Processed By: __________ Date: ____________ Processed By: __________ Date: ____________