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Consent Form for Disclosure to Parents/Guardians, Financial Sponsors, and Agents
To: Registrar, Florida International University
Managing Director, Global First Year
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...
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
Consent
If you agree that FIU or Global First Year may disclose information from your education records to your parent(s)/guardian(s), your sponsor (if applicable), or your recruiter, please sign the following consent:
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 Florida International University or Global First Year as appropriate. I understand that my education records may be disclosed to my Parent(s)/Guardian(s) through the Recruiter and that the Recruiter 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
Florida International University,
but I may revoke the consent by written notice at any time.*
I consent to the disclosure
I do not consent to the disclosure
Parent(s)/Guardian(s)
1.
Name:
Email Address:
Telephone Number:
2.
Name:
Email Address:
Telephone Number:
Sponsor
Name:
Email Address:
Organization:
Telephone Number:
Recruiter
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 Florida International University if they refuse to provide consent.
Contact Information