Consent Form for Disclosure to Parents/Guardians, Financial Sponsors, and Agents

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Consent Form for Disclosure to Parents/Guardians, Financial Sponsors, and Agents

To: Registrar, Cleveland State University

Managing Director, Cleveland State Global

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 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 Cleveland State University and Cleveland State 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 Cleveland State University, as well as any circumstances affecting my attendance at the Cleveland State University. 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 Cleveland State University, 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 "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 Cleveland State University if they refuse to provide consent.

Contact Information