EASTERN MICHIGAN UNIVERSITY
AUTHORIZATION TO RELEASE FERPA PROTECTED INFORMATION
Federal law prohibits EMU from discussing information with anyone other than the student, unless authorized in writing by the student.
This is effective until the cancellation of release has been requested by the student. Please submit form to either Service EMU (McKenny
Hall or the Student Center)
Section I – STUDENT INFORMATION
Student’s Name
E- Number or SS # (last 4 digits)
Section II – AUTHORIZATION INFORMATION (Please complete section I also)
I authorize only the person or persons listed below to receive information
I Name Relationship SS# (last 4 digits)
E-Mail Address
II Name Relationship SS# (last 4 digits)
E-Mail Address
I authorize EMU to release the following information (Check all that apply)
Academic Information: (including but not limited to) Grades, Enrollment Level, Course Selection, Attendance
Financial Aid Information: Satisfactory Academic Progress, Grade Point Average, FAFSA (Free Application for
Federal Student Aid) Information, Award Amounts
Student Account Information: Account Balances, Account Charges, Billing, Payments
Section III – CANCELLATION OF RELEASE (Please complete section I also)
I request the person or persons’ authorization listed below to be cancelled
I Name Relationship
II Name Relationship
I request the cancellation of the release of the following information (Check all that apply)
Academic Information: (including but not limited to) Grades, Enrollment Level, Course Selection, Attendance
Financial Aid Information: Satisfactory Academic Progress, Grade Point Average, FAFSA (Free Application for
Federal Student Aid) Information, Award Amounts
Student Account Information: Account Balances, Account Charges, Billing, Payments
Student’s Signature Date
For office use only:
Receiving Office Processed by Date
Revised 3/29/16
