FERPA Authorization

About This Form

In accordance with The Family Educational Rights and Privacy Act (FERPA) of 1974, Clarke University will only disclose confidential information from the education records of students to parents or other third parties provided the University has written consent from the student on file, except for allowable exclusions. Complete the form if you consent for the University to release your education records to your parents or any other third-party upon their request. Information about FERPA is available by clicking here.

Please note: This release form will remain valid through the student’s enrollment at Clarke University unless specifically revoked by this student.

Fields marked with an * are required

Student Information

Non Clarke Email Address *

First Name *

Middle Name

Last Name *

Birthdate *

Authorized Individuals

Individual One

Relation to student *

First Name *

Last Name *

Address *

Country

Street

City

Region

Postal Code

Phone *

Email Address *

1. Add an additional Authorized Individual? *

Yes

No

Individual Two

Relationship *

First Name *

Last Name *

Address *

Country

Street

City

Region

Postal Code

Phone *

Email Address *

2. Add an additional Authorized Individual? *

Yes

No

Individual Three

Relationship *

First Name *

Last Name *

Address *

Country

Street

City

Region

Postal Code

Phone *

Email Address *

3. Add an additional Authorized Individual? *

Yes

No

Individual Four

Relationship *

First Name *

Last Name *

Address *

Country

Street

City

Region

Postal Code

Phone *

Email Address *

Authorization

By electronically signing below, I consent that Clarke University may disclose and discuss confidential information from my education record with the individuals listed above:

Student's Signature *

Date *

Thank you for providing this information. If you need to make any changes or updates, please contact the Registrar's Office at (563)588-6314