The Family Educational Rights and Privacy Act of 1974 (FERPA)

NOTE: YOU MUST FILL OUT ALL FORM FIELDS OR YOUR FORM WILL BE DISREGARDED

AUTHORIZATION TO DISCLOSE AND USE INFORMATION

The Family Educational Rights and Privacy Act of 1974 (FERPA), as amended, provides for the confidentiality of student educational records. The University of Connecticut may neither disclose certain educational information concerning students nor permit inspection of their educational records without the permission of the student unless such actions are covered by certain exceptions as stipulated in FERPA.

I consent to the University of Connecticut’s release and use of my employment records maintained by the Department of Recreational Services. The University of Connecticut will only disclose the employment records for the following purpose:

Name of Student
Email Address
Phone Number
Person(s) with whom information can be released (please separate multiple individuals with a comma):
Choose your supervisor	Patti Bostic Silvia Chan Mike D'Alfonso Jay Frain John Huck Bhavin Parekh Nigel Roberts

Dates in effect:	to (MM/DD/YY) e.g.. 09/07/05
Student’s Signature (please type initials):
Date:	(MM/DD/YY) e.g.. 09/07/05