Authorization to Release Educational Records

This form must be completed and submitted to the Office of the Registrar to authorize the release of educational information to a third party. This authorization does not give authority to make changes to the student’s educational record.

Only the student in accordance with the Family Educational Rights and Privacy Act of 1974 (FERPA) can authorize release of education information to a third party.
Only copies of records will be provided, not the actual records themselves.
While it is standard for institutions to charge for record requests, such as transcripts, RVU does not; however, expedited mail requests and reissued diplomas will require an additional fee. Current students can print unofficial transcripts via MyVista.

Student name:*

First Last

Program:*

DO
MSBS
MMS
PA

Campus:*

Colorado
Montana
Utah

Class or graduation year:*

Date of birth:*

Student ID or last 4 digits of SSN:*

Phone:*

Email:*

Authorized educational information for release:*

Check all that apply.

Background/health records
Diploma copy
Enrollment/registration information
Transcripts/grades
Other

Please specify for other:*

Comments:

Authorized third party:*

Add additional third parties as needed.

NAME	ADDRESS	PHONE NUMBER	EMAIL ADDRESS	RELATIONSHIP TO STUDENT (PARENT/GUARDIAN, SPOUSE/PARTNER, SPONSOR, OTHER THIRD PARTY)

Acknowledgement:*

I agree to these terms.

· I understand that records are maintained at various offices throughout RVU, and that this request pertains to all relevant offices within RVU. By signing this form, I hereby authorize that these office(s) provide the records and/or information above to the third parties I have listed.

· I understand that the specified information provided to the third parties listed may be released verbally and/or in written/electronic format. Also, although I give my consent, RVU offices reserve the right to refuse release of the information at their discretion where relevant under FERPA.

· I understand that the specified information will be made available only if requested by the listed third parties. The university will not automatically send information to a third party.

· I understand that this request will be honored until the Office of the Registrar receives written authorization from me to revoke this request.

Signature:*

Date: