FERPA Consent Form

Form Information

FERPA prohibits Emory College of Arts and Sciences from releasing your grades, academic information, or conduct/honor records without your consent. To authorize/not authorize Emory College of Arts and Sciences to share pertinent academic information with specific individuals, please answer the following questions and electronically sign this form.

Names and current contact information for your authorized person(s) must be maintained on the FERPA Consent Form. Before submitting this form, please review the information you enter for each contact to verify that it is accurate. If changes occur, you may update your existing FERPA Consent Form by returning to the form and logging in with your netID and password. Any updates made to this form will override your original submission.

Please note the contact information entered on this form is strictly for the release of FERPA-protected information. If you wish for any of the individuals on this form to receive general emails and communications from Emory (not related to your educational records), then you will need to add them to the Parent/Guardian section of your profile in OPUS. If you wish for any of the individuals on this form to have direct access to your OPUS account, you may accomplish this through the Guest Access tile in OPUS.

Student Information

❗ Alert! If you are unable to complete any of the required fields in this section, please log-in using your Emory credentials for full access to this form.

Emory Student ID Number (EMPLID)*

Emory Email Address*

Preferred First Name (Optional)

Last Name*

Note: The Preferred First Name field will be blank if you do not have a preferred name on record in OPUS. Visit the 'Profile' tile in OPUS to update your official contact information. Step-by-step instructions can be found here: Updating Preferred Name. It takes approximately one week for Preferred Name updates in OPUS to be reflected in College Connect.

Consent

Please indicate Yes or No for Consent of Information

By indicating “Yes” and submitting the form, I hereby authorize and request the Dean of Emory College of Arts and Sciences, or his/her designated representative(s) in the Office for Undergraduate Education, to furnish the authorized person(s) named below information related to my academic life at Emory College of Arts and Sciences. I hereby authorize release of information, including a copy of any notification to me regarding academic probation or exclusion from the College, or general advisory letters based on academic performance. I also give authorization for the Dean of Emory College of Arts and Sciences, or her/his designated representative, to discuss my academic performance, including grades and other related issues, with below said person(s). I understand that I may change this authorization only by submitting a new FERPA Consent form.

By indicating “No” and submitting the form, or by failing to submit this form, I understand that the Dean of Emory College of Arts and Sciences, or his/her designated representative, cannot release the above information unless my parent(s) or guardian(s) claim me as a dependent. I understand that I may change this authorization only by submitting a new FERPA Consent form. I also understand that academic regulations concerning probation and exclusion will not be waived should the Dean of Emory College of Arts and Sciences fail to comply with this request.

I authorize the Dean of Emory College and/or designated representatives to furnish the authorized person(s), as listed on this form, the above information.*

Yes

No

Authorized Person #1

Enter the contact information for the first authorized person you wish to have access to the above information.

Is Authorized Person #1 your parent/guardian?*

Yes

No

Authorized Person #1 - First Name*

Authorized Person #1 - Last Name*

Authorized Person #1 - Phone Number

Authorized Person #1 - Email Address

Authorized Person #1 - Country

Authorized Person #1 - Street Address

Authorized Person #1 - City

Authorized Person #1 - State

Authorized Person #1 - Zip/Postal Code

Is there a second authorized person who you wish to have access to the above information?*

Yes

No

Authorized Person #2

Enter the contact information for the second authorized person you wish to have access to the above information.

Is Authorized Person #2 your parent/guardian?*

Yes

No

Authorized Person #2 - First Name*

Authorized Person #2 - Last Name*

Authorized Person #2 - Phone Number

Authorized Person #2 - Email Address

Authorized Person #2 - Country

Authorized Person #2 - Street Address

Authorized Person #2 - City

Authorized Person #2 - State

Authorized Person #2 - Zip/Postal Code

Is there a third authorized person who you wish to have access to the above information?*

Yes

No

Authorized Person #3

Enter the contact information for the third authorized person you wish to have access to the above information.

Is Authorized Person #3 your parent/guardian?*

Yes

No

Authorized Person #3 - First Name*

Authorized Person #3 - Last Name*

Authorized Person #3 - Phone Number

Authorized Person #3 - Email Address

Authorized Person #3 - Country

Authorized Person #3 - Street Address

Authorized Person #3 - City

Authorized Person #3 - State

Authorized Person #3 - Zip/Postal Code

Is there a fourth authorized person who you wish to have access to the above information?*

Yes

No

Authorized Person #4

Enter the contact information for the fourth authorized person you wish to have access to the above information.

Is Authorized Person #4 your parent/guardian?*

Yes

No

Authorized Person #4 - First Name*

Authorized Person #4 - Last Name*

Authorized Person #4 - Phone Number

Authorized Person #4 - Email Address

Authorized Person #4 - Country

Authorized Person #4 - Street Address

Authorized Person #4 - City

Authorized Person #4 - State

Authorized Person #4 - Zip/Postal Code

Authorization

I certify that I am providing accurate and true information on this waiver form.*

I agree

Please type your full legal name below in place of your signature.*

Please enter today's date using the following format: MM/DD/YYYY.* Note: If you are updating your original FERPA Consent form, the date you originally submitted the form will populate here. Please make sure to change the date to the current date to update your responses.

Buckley Amendment: Confidentiality - Use of the data requested is governed by Federal Law (P.L. 93-280 as amended, the "Family Educational Rights and Privacy Act of 1974",also known as FERPA). Recipients of such data are responsible for compliance with the subject acts, which govern the use and dissemination of educations records, as are those releasing such information.