FERPA Information Release Form About Mercy FERPA Information Release Form FERPA Request for Records Release, Records Inspection & Directory Opt-Out 黑料网 Please fill in a valid value for all required fields Please ensure all values are in a proper format. Are you sure you want to leave this form and resume later? Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form. Save and Resume Later Save and get link You must upload one of the following file types for the selected field: There was an error displaying the form. Please copy and paste the embed code again. Apply Discount You saved with code Submit Form Submitting Validating There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue. Please check the field: Fields FERPA Request for Records Release, Records Inspection & Directory Opt-Out Student Name:* First Name* Middle Name* Last Name* Student CWID:* Student Social Security Number:* Release Information or Cancel Release:* Release information to the third party that I list below Cancel my authorization to release information to the third party that I list below Choose One:* This FERPA Release is for a Person This FERPA Release is for a Group/Organization Name of Person Referenced Above:* First Name* Last Name* Name of Group/Organization Referenced Above:* YPIE - Yonkers Partners in Education KIPP BloomBoard Choose One Relationship to Student:* Address of Third Party Listed Above: Address Line 1 Address Line 2 City 听 Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State ZIP Code I authorize (or cancel) the items checked below:* Grades/GPA, demographic, registration, student ID number, and academic status progress, enrollment information Financial Aid awards, application data, disbursements, eligibility, and/or financial aid satisfactory academic progress status Billing statements, charges, credits, payments, past due amounts, and/or collection activity Other: Other Value Other Other Additional request Withhold my Directory Information An inspection of my academic records. Other: Other Value Please select one or more options If Other, Please Specify: Today's Date:* https://www.formstack.com/forms/images/2/calendar.png Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 Signature (Full Name):* Previous鈫 Next鈫 Enter your save and resume password Cancel Confirm