Student Consent for Release of Information to Parents/Third Parties

The Family Educational Rights and Privacy Act (FERPA) of 1974, as amended, seeks to guarantee both a student’s right of access to records and the confidentiality of student information. Institutions may not disclose information contained in student records without the student’s written consent except under certain conditions. Under the FERPA, a parent may access his/her child’s grades and other education record information in two ways:

1) If the student consents in writing to the release; or
2) If the parent claims the student as a dependent on his/her federal income tax return

If you have any questions, please contact the Dean of Students for the Scooba Campus at 662-476-5000 or the Dean of Students for the Mayhew Campus at 662-243-1979.

First Name: *

Middle Name:

Last Name: *

Student ID Number: *

Student Consent
Check below to indicate which records you wish to make available: *

Financial Records Financial Aid, Account Records)

Academic/ Transcript Records (Grades, Progress, Attendance)

Discipline Records

All Educational Records

I DO NOT want to share my information with anyone

Release Information to:

Name:

Relationship:

Name:

Relationship:

Name:

Relationship:

I understand the information may be released orally or in the form of copies of written records, as referred by the requester. This authorization will remain in effect from the date it is executed until revoked by me, in writing, and delivered to the Office of the Registrar.

Student Signature *

clear

East Mississippi Community College does not discriminate on the basis of race, color, national origin, sex, disability or age in its programs or activities. The following person has been designated to handle inquiries regarding the nondiscrimination policies: Lapari Morant/ Associate Dean of Students / 123 F.R. Young Student Union, Scooba, MS 39358 / 662.476.5443 / lmorant@eastms.edu