To submit your FERPA form, please

American Collegiate, Los Angeles FERPA Form

All students age 18 and older will need to complete the online FERPA form. Students under the age of 18 will need to complete the paper version of the FERPA form here, then email the completed form to StudentServices.LA@americancollegiate.com

To: Registrar, UCLA Extension

Director, American Collegiate, Los Angeles

Student Information

Given/First Name

Middle Initial

Family/Last Name

Student ID

Date of Birth

Month

Day

Year

Consent

Please read the following statement regarding the disclosure of personally identifiable information and your education record. If you agree with the statement, please click “I consent” below. If you do not agree with the statement, please click “I do not consent” below.

I consent to the disclosure of any personally identifiable information and my education records to the individual(s)/organizations(s) named below, and to American Collegiate, Los Angeles staff, for the purpose of informing said parties of my progress and status at UCLA Extension, as well as any circumstances affecting my attendance at UCLA Extension. I understand that my education records may be disclosed to my Parent(s)/Guardian(s) through my Agent/Education Counselor and that my Agent/Education Counselor may only re-disclose education records to my Parent(s)/Guardian(s) identified below. This authorization will remain in effect for the duration of my tenure at the UCLA Extension, but I may revoke the consent by written notice at any time.*

I consent to the disclosure of any personally identifiable information from my education records to the individual(s)/organization(s) named below. (Please provide the information below and click "Submit." It is not required to fill all available fields.)I do not consent to the disclosure of any personally identifiable information from my education records. (Please click "Submit" below to record your response.)

Parent(s)/Guardian(s)

Name:	Email Address:
Telephone Number:

Name:

Email Address:

Telephone Number:

Financial Sponsor

Name:

Email Address:

Organization:

Telephone Number:

Agent/Education Counselor

Name:	Email Address:
Organization:	Telephone Number:

Submit

To complete the FERPA submission process, follow these steps:

Click the "Next" button below.
Review your information on the form that opens.
Add your e-signature and click the "Submit Signed Response" button.
Once you have submitted your e-signature, a verification email will be sent to you. Click the link in the email you receive to complete the submission process.

*Students cannot be denied any educational services from the UCLA Extension if they refuse to provide consent.

Contact Information