Disclosure Form
Email address
Disclosure to Parent(s)/Guardian(s) and Consent to Disclose Student Records
Under the Family Education Rights and Privacy Act (FERPA), Emory & Henry College is permitted to disclose any and all information from your educational records* to your parent(s)/guardian(s) if you are dependent for tax purposes. The College would like students to identify personally those parties to which information about enrollment may be shared.
Student’s Full Name
Your answer
Educational Records
I _________________________ to the disclosure of personally identifiable information from my educational records* to my parent(s) and/or guardian(s), or others designated below, for reasons determined by Emory &Henry College as appropriate.
Directory Information
I _________________________ to the release of directory information** for educationally related matters, including research studies for reasons determined by Emory & Henry College as appropriate.
Person(s) to release information to:
Full Name, 1 Per Line
Your answer
Additional Info
NOTE: Not completing this form implies consent to release directory information**.

Not consenting to release of directory information will result in the College responding to any inquiry about your enrollment by stating, “We have no information available about a person with this name.” Your name will not be printed in the commencement program and cannot be released in the context of athletic activities or participation in cultural and service activities, including theatrical productions. Other consequences of this restriction include not having your name published in your home newspaper for honors or awards issued by Emory & Henry College.

* Educational records are any and all records kept by Emory & Henry College, including but not limited to academic, student life, financial aid and/or billing records.

** Directory information includes name, address(es), email address(es), phone number(s), major and minor field of study, current enrollment status and class standing, photos and video of students engaged in E&H activities, participation in officially recognized activities and sports, height and weight information for student athletes, dates of attendance, expected date of graduation and date of graduation including honors awarded.

Students cannot be denied any educational services from Emory & Henry College if they refuse to provide consent. Return this completed form to the Centralized Student Assistance Office.

Student Signature
Your answer
Date
MM
/
DD
/
YYYY
* By typing your name and date, you are confirming the above information is accurate and correct, was typed by the name owner, and will function as a legal and binding signature once submitted with your form.Untitled Title
Text Alerts
If you wish to receive text alerts related to your enrollment, provide your cell phone number and carrier (AT&T, Verizon, T-Mobile, etc.).
Cell Phone Number
Your answer
Carrier
Add your carrier to the "Other..." option if you do not see it listed.
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
Submit
Never submit passwords through Google Forms.
This form was created inside of Emory and Henry College. Report Abuse - Terms of Service - Additional Terms