Student Release of Information (FERPA)

Student Release of Information

Family Educational Rights and Privacy Act Regulations (FERPA)
In compliance with the Family Educational Rights and Privacy Act of 1974 (FERPA), Bridgerland Technical College requires the written consent of the student authorizing the disclosure of student information from their records. The authorization must include: the speciﬁc information to be released; the party or class of parties to whom the information is to be released; the purpose of the release; the date; and the student’s signature.
PHOTO ID IS REQUIRED. Students must present photo ID when submitting this form in-person, or provide a copy of photo ID when submitting the form via mail, fax or email.
Student Information
Name

First NameLast Name
BTECH ID #
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Student Record(s) to Release (check all that apply)

Other
Release to:

Who can we release your record(s) to?
Individual/Company Name:
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
Reason for Release?
Why do you want us to release your records to the above mentioned third party?
Expiration Date

When do you want the release to expire?
Expiration Date
If no expiration date is input, this release will expire 6 months after exiting BTECH. You can input a specific expiration date or input 'no expiration date' if you do not want the release to expire.
I understand that the information speciﬁed on this form is being released to a third party at my request, with the understanding that this party will not release it to any other parties. Bridgerland Technical College is hereby released from all legal responsibility or liability for the release of the above-referenced information.
Signature

Clear
Date

MonthDayYear
Photo Identification (driver's license or other government issued ID) is required to submit the form. Please upload here.

Cancelof
Should be Empty:

Student Release of Information

Student Information

Release to:

Expiration Date