Application for Admission to Graduate & Professional Studies ...

Student Release of In<strong>for</strong>mation FormUnder the Family Educational Rights and Privacy Act (FERPA-commonly known as the Buckley Amendment)regulations, Direc<strong>to</strong>ry In<strong>for</strong>mation is defined as in<strong>for</strong>mation that may be released without a student's consent.This in<strong>for</strong>mation includes: student's name, campus center and home addresses, major field of study, dates ofattendance, degrees and awards received, participation of officially-recognized activities and sports, and theheight and weight of athletes. This Direc<strong>to</strong>ry In<strong>for</strong>mation may be released upon request unless the Registrarreceives a written request from the student directing otherwise.Special written permission is needed <strong>to</strong> release any other confidential in<strong>for</strong>mation <strong>to</strong> persons beyondFranklin Pierce University and its agents. *(There are some exceptions <strong>to</strong> this.) Students often want <strong>to</strong> haveacademic or financial in<strong>for</strong>mation released <strong>to</strong> their parents or spouses. This <strong>for</strong>m allows you <strong>to</strong> give suchwritten permission.Print Legal Name: ______________________________________________________ Date: ___________Student ID Number: _____________________________ Academic Advisor: _______________________Academic In<strong>for</strong>mation: by placing names on the lines below you are giving Franklin Pierce Universitypermission <strong>to</strong> release your Confidential Academic In<strong>for</strong>mation <strong>to</strong> the people listed. If you do not wantConfidential Academic In<strong>for</strong>mation released <strong>to</strong> anyone, leave this section blank.Name Relationship Telephone Number_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Financial In<strong>for</strong>mation: By placing names on the lines below you are giving Franklin Pierce Universitypermission <strong>to</strong> release your Confidential Financial In<strong>for</strong>mation <strong>to</strong> the people listed. If you do not wantConfidential Financial in<strong>for</strong>mation released <strong>to</strong> anyone, leave this section blank.Name Relationship Telephone Number______________________________________________________________________________________________________________________________________________________________________________Preferred Newspaper(s): By providing your home<strong>to</strong>wn newspaper(s) on the lines below you are indicating <strong>to</strong>Franklin Pierce University where you would like <strong>to</strong> have any notices of your special accomplishments andactivities sent. If you do not have a preference, please leave this section blank.Home<strong>to</strong>wn NewspaperCity and State____________________________________________________________________________________________________________________________________________________________________________This Consent <strong>to</strong> the Release of In<strong>for</strong>mation is <strong>to</strong> remain valid until my graduation. I understand that this <strong>for</strong>mmay be changed or updated at any time by signing a new <strong>for</strong>m. Each new <strong>for</strong>m must contain all permissions thatI wish <strong>to</strong> give even if some in<strong>for</strong>mation has not changed. Forms are available online, through StudentAdministrative Services or the Registrar's Office.Student Signature: _________________________________________________ Date: ________________*For a list of exceptions please, refer <strong>to</strong> The Student Handbook, section 5, number 4, entitled "Release of In<strong>for</strong>mation."5