GALVESTON COLLEGE

Authorization to Disclose Non-Directory Information to a Third Party

Student Name (print)

Student ID

The Family Educational Rights and Privacy Act Of 1974 (FERPA - Family Educational Rights and Privacy Act)

The Family Educational Rights and Privacy Act of 1974 prohibits Galveston College from releasing certain student information without your written consent. As a student, you have the right to allow a third-party access to this information.

Additional information regarding FERPA and your rights under FERPA can be found in the Galveston College Catalog.

I wish to allow the party/parties below access to my personally identifying information. I understand my rights under FERPA and release Galveston College from all liability related to the release of the specified information to myself or the individual(s) listed below.

I wish to allow _________________________________________________________________ access to the records listed below:

______ Any and all records/personally identifying information

______ Academic records (transcript, GPA, grades, progress in course(s), etc.)

______ Financial records (financial aid, current balance, charges on account, etc.)

_____ Alcohol and Drug Abuse testing/treatment

______ Other: ______________________________________________________________________________

Student Signature Date