LMU FERPA FORM

Family Educational Rights and Privacy Act

Dear Dean of Students

As you know, I _______________________________, will be attend Lincoln Memorial University this semester. It is very important that my parent(s) and/or guardian(s) and I continue open lines of communication during my time in college. Therefore, we have agreed to this by providing your office with appropriate signature below.

This permission allows you to release information to the following people

Name:______________________________________________Relationship_____________________________

Name:______________________________________________Relationship_____________________________

concerning the below circled or indicated items:

• Disciplinary Issues
• Mental Health Issues
• Residential Life Issues
• Academic Issues
• Finance Issues

Other topics of issues important to me:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

I, ___________________________________________, hereby provide written authorization, as required under 2OUSCS123 (FERPA ACT), to any records or information as indicated above to those individuals listed above.

_____________________________________________          _______________________________________                                                        Student Signature                                                                          Date