Release of Information Authorization form

Michigan State University

Student Name ____________________________________________ Student Number _____________________

I hereby authorize Michigan State University to release the following information from my education records:

_______________________________________________________________________________________________

to (provide name and address of person/agency to receive information): _____________________________________

_______________________________________________________________________________________________

for the purpose of:_______________________________________________________________________________

_______________________________________________________________________________________________

I understand that I have the right not to consent to the release of my education records and I have the right to inspect

and review such records upon request.

Time limit (consult with the department/office to determine the most appropriate option):

__________ I understand this consent is in effect this one instance; once this request is fulfilled, the consent will be

null and void. (Some offices will only accept this as an option for release)

__________ I understand this consent shall remain in effect until revoked by me, in writing, and delivered to

Michigan State University. However, any revocation shall not affect disclosures previously made by

Michigan State University prior to the receipt of any such written revocation.

___________________________________________________________ _____________________________

Student’s Signature Date

Information released to a third party pursuant to this authorization is subject to the confidentiality provisions provided

under the Family Educational Rights and Privacy Act (FERPA) and may not be made available to any other party

without the written consent of the student.

Last updated: 10/2023

Michigan State University

Release of Information Authorization form

Instructions for Department/Unit

The student should provide the unit this form directly, either via hand-delivery or their MSU e-mail. The disclosing

unit is responsible for retention of this form in alignment with other MSU policies. The unit may have designated

specific individuals within the unit to release information from education records. This form allows the unit but does

not require the unit to disclose information contained within the specified records.

Instructions for Student

This completed form must be submitted by the student to the department that holds the record(s) the student is

authorizing to release. Departments may accept e-mailed copies from the student's official MSU e-mail address or

with a hand-delivered wet signature. The student should not provide the signed form to the third party; the

department will not accept it. A separate authorization must be completed for each department.

Instructions for Third Party

This form authorizes MSU officials to disclose information within the specified records, but it does not obligate

them to disclose. The student should provide the signed form directly to the department. Some departments may not

accept a durable release, and may require a new release for each new disclosure.

If you have questions regarding this form or for any other FERPA related issues, please contact the FERPA

Compliance Office at [email protected].

Last updated: 10/2023