FERPA Student Information Release Form
Please complete this form in person at the Registrar’s Office, one form per 3rd party to be authorized.

Student CWID: ________________________
Office Use Only:





Student Name:
________________________

(Clearly Print Full Name)
Processed By

Date


I (Student Legal Name Printed)_______________________________________, hereby authorize the Colorado School
of Mines to disclose, make accessible, and furnish the following information only to the specified 3rd parties below. I
understand that this FERPA Student Information Release Form only applies to in-person or telephone
communication. There is no email or online option or portal for parents or authorized third parties to use to gain
access to my personal student information or to order official university credentials.
○ Official Transcript (Registrar’s Office)
○ Current Term Grades Only - Includes Overall GPA (Registrar)
○ All Contents of Registrar’s Office File (Registrar)
○ Attendance Information as Observed by __________________________________(faculty member)
○ Academic Performance as Observed by __________________________________(faculty member)
○ Advising Information Held by _____________________________________________(advisor name)
○ Judicial Affairs File(s) of the School (Student Affairs)
○ Student Accounts Information (Student Receivables)
○ Departmental File(s) ______________________________________________(name of department)
○ Department of Residence Life File(s) (Student Affairs)
○ Faculty Recommendation Including g.p.a. and Academic Performance
○ Other: - Description ________________________________________________________________

3rd Party Authorization:
Only the following third party are authorized with this student information release

Full Name:
________________________________________________


Address:
________________________________________________


Phone Number: ________________________________________________


Security Passphrase
Please choose a security passphrase that will be used to identify the third party person authorized to access
your student records. Do not disclose this password to any other third party who are not authorized)

Security
________________________________________________
Passphrase:

These records will be used for the sole purpose of:
__________________________________

This release shall be effective unless revoked by me in writing till the following date: __________________



Student Signature
Date

registrar@mines.edu • PHONE: 303-273-3200 • Fax: 303-384-2253 • 1200 16th Street Suite E280, Golden, CO 80401