COB - Internship FERPA Release

Valparaiso University | College of Business
1909 Chapel Drive | Urschel Hall | Valparaiso, IN 46383
Phone: 219.464.5963 | Email: brett.calland@valpo.edu
Brett Calland, Advising & Practical Experience Coordinator

Student Name Student Name First Last
ID Number
Must be 7 digits. Currently Entered: 0 digits.
Date of Birth Date of Birth / MM / DD YYYY
I, the undersigned, hereby authorize Valparaiso University (VU) to release the following records and information (identify records or type of records):

Any and all education records and all matters related to the student's internship with
Name of Organization or Company
to (Name and Address of Person/Agency to Receive Information)

Example: Supervisor Name and Address
for the purpose of:

MGT-395 Internship Experience in Business Administration I
I understand further that: (1) I have the right not to consent to the release of my education records; (2) I have a right to receive of copy of such records upon request; (3) and that this consent shall remain in effect until revoked by me, authorizing any re-disclosures until such revocation, in writing, and delivered to VU, and that any such revocation shall not affect disclosures previously made by VU prior to the receipt of any such written revocation.
By signing electronically below, I confirm that I am able to access information in an electronic form and I also agree that the institution does not need to provide me with an additional paper (non-electronic) copy of the document unless specifically requested. Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
THIS INFORMATION IS RELEASED SUBJECT TO THE CONFIDENTIALITY PROVISIONS OF APPROPRIATE STATE AND FEDERAL LAWS AND REGULATIONS WHICH PROHIBIT ANY FURTHER DISCLOSURE OF THIS INFORMATION WITHOUT THE SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS, OR AS OTHERWISE PERMITTED BY SUCH REGULATIONS.
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COB - Internship FERPA Release

COB - Internship FERPA Release

I, the undersigned, hereby authorize Valparaiso University (VU) to release the following records and information (identify records or type of records): Any and all education records and all matters related to the student's internship with

for the purpose of: MGT-395 Internship Experience in Business Administration I

I, the undersigned, hereby authorize Valparaiso University (VU) to release the following records and information (identify records or type of records):

Any and all education records and all matters related to the student's internship with

for the purpose of:

MGT-395 Internship Experience in Business Administration I