Longwood University

Information Release Consent Form

 

By my signature below, I consent to releasing information protected by the Family Educational Rights and Privacy Act of 1974 (FERPA, as amended in 1988), information protected by the Gramm-Leach-Bliley Act (GLBA) to the following individuals:

Please legibly print full names (first, middle initial and last) of any individuals that you are allowing information to be released to.

                                                                                                                                         

                                                                                                                                         

                                                                                                                                         

                                                                                                                                         

                                                                                                                                         

                                                                                                                                         

                                                                                                                                         

 

_____________________________________________________________________
Student's full name (PRINT LEGIBLY)                                             Longwood ID #

_____________________________________________________________________
Signature of Student                                                                        Date
 


This form should be mailed, faxed or delivered to the Registration Office.

Registration Office
Longwood University
201 High Street
Farmville, VA  23909
Fax:  434.395.2252