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Consent Form for Disclosure to Parents/Guardians, Financial Sponsors, and Agents
To: Registrar, University of Dayton
Managing Director, Dayton Global
Student Information
Given/First Name
Middle Initial
Family/Last Name
Student ID
Date of Birth
Month
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Day
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Please select...
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Consent
Please read the following statement regarding the disclosure of personally identifiable information from 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 from my education records to the individual(s)/organizations(s) named below, for reasons determined by the University of Dayton and
Dayton Global
as appropriate. I understand that the purpose of the disclosure is to inform the parties listed below of my progress and status at
the University of Dayton
, as well as any circumstances affecting my attendance at
the University of Dayton
. 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 t
he University of Dayton
, 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)
1.
Name:
Email Address:
Telephone Number:
2.
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 "Submit" 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 University of Dayton if they refuse to provide consent.
Contact Information