ࡱ> .0-k bjbj:: 0XubXub  *$"YYY YYYYБ4rjY0*YvvYvY<Y5$*vB Z: FERPA Release Form AUTHORIZATION FOR THE RELEASE OF STUDENT INFORMATION TO WHOM IT MAY CONCERN: I, _____________________________________, hereby authorize ÿմ (SMSU) to release and/or orally discuss the educational records described below about me to: First Name: __________________________________________________ Family Name: ________________________________________________ Relationship to the Student: _____________________________________ Email: ______________________________________________________ Working Phone Number or Cellular Phone: _________________________ The specific records covered by this release are: health, student conduct and disciplinary issues, academic records. The persons to whom the information may be released, and their representatives, may use this information for the following purposes: Study Abroad emergency situations; such as accidents, illness, deaths, and other emergency situations that may warrant the need to share information with the specific individual (s) noted above for the health and safety of the individual student. I understand that the student records information listed above includes information which is classified as private on me under Minn. Stat. 13.32 and the Federal Family Education Rights and Privacy Act. I understand that by signing this Informed Consent Form, I am authorizing the College/University to release to the persons named above and their representatives information which would otherwise be private and not accessible to them. I understand that without my informed consent, the College/University could not release the information described above because it is classified as private. I understand that when my education records are released to the persons named above and their representatives, the College/University has no control over the use the persons named above or their representatives make of the records which are released. I understand that, at my request, the College/University must provide me with a copy of any educational records it releases to the persons named above pursuant to this consent. I understand that I am not legally obligated to provide this information and that I may revoke this consent at any time. This consent expires upon completion of the above stated purpose or after one year, whichever comes first. However, if the above-stated purpose is not fulfilled after one year, I may renew this consent. A photocopy of this authorization may be used in the same manner and with the same effect as the original documents. I am giving this consent freely and voluntarily and I understand the consequences of my giving this consent. Students First Name: ____________________________________________________ Students Family Name: __________________________________________________ Students Signature: ____________________________________ Date: ___________ 01IJ   ! o q 7 8 m n f g )*AEJgopqùèèááá٘hThTCJ hThT hTh2fhTh156hTh2f56 hTh1 h2fCJh2fh2fCJ h1CJ hTCJ hT5CJ h15CJhThT5CJ(aJ(/HIJb! " c d + , o p q 8 g h gd2f&d P `gdT &d P gd2fd$a$(*67gdT.:pT/ =!"#$% s2&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH 8`8 Normal_HmH sH tH DA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w< "  8@0(  B S  ?  P w 3333333301IJ-bp*+,Unqqhh) * A E J g o p v z z | | 01IJ-bp*+,Unqqfhh) * A E J g o p v z z | |  m$12fT%dFl @   @UnknownG.[x Times New Roman5Symbol3. .[x ArialA$BCambria Math"h3‰G5  !24 3HP ?d2!xx)l5 AUTHORIZATION FOR THE RELEASE System OfficeMay Lee Moua-Vue Oh+'0  (4 T ` lx AUTHORIZATION FOR THE RELEASESystem OfficeNormalMay Lee Moua-Vue6Microsoft Office Word@~mg@z0y@ 4r  ՜.+,0 hp  MnSCU  AUTHORIZATION FOR THE RELEASE Title  !"#$&'()*+,/Root Entry Fۂ4r11TablevWordDocument0SummaryInformation(DocumentSummaryInformation8%CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q