FERPA RELEASE OF INFORMATION FORM

REGISTRAR'S OFFICE

Name*

Please enter your legal name

First Middle Last

Select Identification*

You must enter either your Student ID Number or the last four Digitis of your SSN

Tusculum ID Number
Social Security Number

Student ID Number*

Enter your 6-digit Tusculum ID, including zeros.

Last 4 digits of Social Security Number*

Enter the last 4 digits of your Social Security Number

Entry Term*

Please enter the term you entered or will enter Tusculum University.

Federal Family Educational Rights and Privacy Act and Tennessee Student Information in Higher Education Act Release of Information Request/Authorization

While the Family Educational Rights and Privacy Act of 1974 (20 U.S.C. §1232) prohibits the release, to third parties (not inclusive of individuals with an educational need to know), of information contained in a student’s educational records without the express written consent of the student or of a guardian of whom the student is a dependent (excepting the notification of parents or guardians of students under the age of 21 in cases of alcohol and drug related violations, and victims in violence related incidents) the University complies with the Tennessee Student Information in Higher Education Act of 2005 in seeking to make student information readily available to students and parents to promote an educational partnership.
Nonetheless, students or parents requesting such release must complete this document to allow the University to work with them while satisfying the federal regulations.

Student Request

I hereby request/authorize personnel at Tusculum University to disclose information or copies of:

Record selection*

ALL RECORDS maintained by the institution
Only Academic
Only Co-curricular
Only Financial
NO RECORDS released

Release only to the following individual(s): (Educational records will only be released to the individuals listed below)

1. Name of authorized individual

First Last

1. Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

1. Relationship to Student

2. Name of authorized individual

First Last

2. Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

2. Relationship to Student

This authorization will continue through the remainder of the student’s academic career at the University or until such time as it is revoked in writing or overridden by declaration of the student as to independent status. This information may be transmitted in person, through electronic services or via mail. In signing this document, the individual releases Tusculum University, including its Board, officers, employees, and agents, of any responsibility for misappropriation of the information released.

Signature*

Signature of Requesting Individual

Publicity Information/Image Use Authorization

I hereby authorize Tusculum University to use my name, photographic image/likeness and other information (e.g. service, honors, and achievements) in any and all print, digital and video formats in all publications and broadcasts (e.g. brochures, viewbooks, newsletters, newspaper articles, websites, radio and television interviews/commercials, e-mail notices and community-wide broadcasts). I understand that information and likenesses may be directly solicited or captured without my awareness.

Publicity Authorization*

YES, I hereby authorize Tusculum University to use my name, photographic image/likeness and other information
NO, I DO NOT authorize Tusculum University to use my name, photographic image/likeness and other information

Publicity Signature