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Release of Student Information Buckley Amendment FERPA Waiver Registrar's Department

St. Matthew's University 12124 High Tech Avenue Suite 350 Orlando, FL 32817

Family Educational Rights and Privacy Act of 1974 The Family Educational Rights and Privacy Act of 1974 prohibits the release of privileged information to anyone except authorized personnel. If a student wishes another individual such as parents or spouse to have access to privileged information, he/she must complete the release form and return it to us before any information will be released. It is only necessary to complete this release one time. If there are any changes to this information, the student must notify us immediately. I, _______________________________ Name of Student _______________________________ Student I.D. # Authorize access of my information to: Name __________________________ __________________________ __________________________ ___________________________ Student Signature Relationship __________________________ __________________________ __________________________ __________________________ Date Academic Financial ___________________________ Social Security #

*Waiver will be in effect until rescinded by student in writing.


St. Matthew's University 12124 High Tech Ave., Suite 350, Orlando, FL 32817 Phone ­ 800-498-9700 / 407-488-1700 Fax ­ 800-565-7177 / 407-488-1743 Email ­ [email protected]

REV. 2/2012


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