Bethel University FERPA Information Release Form

Bethel University releases information regarding a student's academic record/performance, financial records, disciplinaryrecords or other educational records to a student's parents/guardians in accordance with THE FAMILY EDUCATIONALRIGHTS AND PRIVACY ACT OF 1974 (FERPA). The Bethel University policy regarding Student Records and Releaseof Information can be found in our catalog. Further information regarding FERPA can also be accessed at theDepartment of Education's Web site (www.ed.gov/offices/OII/ferpa/index).

Academic and financial records and information may be released to parents/guardians without the student'spermission if the student is listed as a dependent on the parent's/guardian's Federal Income Tax return. In addition,Student Life records and information may be released without the student's permission in cases of alcohol and drugviolations or when the student poses a danger to him/herself or others.In accordance with the Family Educational Rights & Privacy Act (FERPA, the Federal Law protecting students'academic records), I make the following declaration. Select one by checking:

1. I am claimed as a dependent on the following persons' IRS Statement and therefore they have access to myAcademic Information*. Such information may be obtained from Bethel University faculty, staff and administrators.

In addition to those listed above by IRS declaration, I grant permission for the following persons or agencies to have access tomy Academic Information*.

2. I am self supporting and claimed by no one but myself or my spouse on my annual Federal Income Tax Statement.I grant my permission for the following person or agencies to have access to my Academic Information*.

3. I am self-supporting and claimed by no one but myself or my spouse on my annual Federal Income Tax Statement.Therefore, my Academic Information* is subject to release only with my written permission.

Student Personal Identification Number:
3 Letters & 3 Numbers ONLY (ex. XYZ-456)

3 Letters                                        3 Numbers

*Any authorized person(s) requestion information must provide this PIN number so choose a number that you will remember and procide it to the authorized person(s).

Please note: If enacted, this declaration is to be filed
with the Registrar's Office. It may be amended by addition
or deletion at any time in writing, otherwise, Bethel University
will use thisdeclaration effective the date of first enrollment until
the student reaches age of 21 or until the student leaves Bethel University.