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Student Information Release Form In accordance with the Family Education Rights and Privacy Act FERPA Subject to certain exceptions set forth in the Federal Family Education Rights and Privacy Act FERPA of 1974 Pima Community College will not provide personally identifiable student information including but not limited to grades billing tuition and fees assessments financial aid and other student records to third parties absent the student s consent. Third parties include parents spouses and third-party designees. You the student may grant Pima Community College permission to release certain information to a third party by submitting this form* A separate form must be submitted for each person to whom you wish to grant access to your records. Any records will be provided only upon request by the third party they will not be sent automatically by Pima Community College. NAME LAST FIRST STUDENT ID NUMBER ADDRESS STREET CITY STATE ZIP PHONE NUMBER Third-party Designee EMAIL ADDRESS Information Types Allowed Check one or more of the boxes below to grant authorization Grades/GPA registration academic performance/standing class schedule transcripts and/or enrollment information Financial aid awards application data disbursements eligibility and/or financial aid satisfactory academic progress Finance-related records including billing statements charges credits payments and past due amounts Other specify Certification By signing below I consent to the release of the personally identifiable student information specified above to the individual listed above. The third-party individual or agency will be asked to provide the following personal security password This consent shall remain in effect through choose one Entire duration of enrollment with Pima Community College Academic Year specify STUDENT SIGNATURE DATE Submit to any campus Student Services Center District Financial Aid and/or Office of the Registrar. To revoke a previous Student Information Release submit a written request to the applicable office s. Office Use Only Staff Name Date Received Noted in SPACMNT FER Noted in RHACOMM FERPA Route to Registrar Student Accounts and/or Financial Aid office as necessary Pima Community College is an equal opportunity affirmative action employer and educational institution committed to excellence through diversity. Upon request reasonable accommodations will be made for individuals with disabilities. Every effort will be made to provide reasonable accommodations in a timely manner. For public and employee accommodation requests as well as information related to the ADA complaint process contact the College ADA Coordinator at 520 206-4539 or 4905C E* Broadway Blvd. Tucson AZ 85709-1130. For PCC student accommodation requests please contact the appropriate campus Disabled Student Resource office 520 206-4500 TTY 520-206-4530 1304BY4D. Third parties include parents spouses and third-party designees. You the student may grant Pima Community College permission to release certain information to a third party by submitting this form* A separate form must be submitted for each person to whom you wish to grant access to your records. Any records will be provided only upon request by the third party they will not be sent automatically by Pima Community College..

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