Authorization to Disclose Information

Requests to Disclose Information

Student education records are official and confidential documents protected by one of the nation's strongest privacy protection laws, the Family Educational Rights and Privacy Act (FERPA). Therefore, non-affiliated third parties (e.g., parents, employers, government agencies, private contractors, etc.) conducting background checks, requesting information about a student’s disciplinary or case management history, or wanting to discuss specific information about a student's need or circumstance will not receive information immediately or over the phone until our office verifies the authenticity of any release, the requester’s credentials, and obtain a signed release from the student.

In certain circumstances, current and former students may also wish to know more information about their student accountability or CARE/case management records. CARE/case management records are managed independently from student accountability records, and CARE/case management files are not included as part of the student accountability processes.

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Your Full Name:

Your Position/Title:

Your Phone Number:

Your Email Address:

Email address must be of a valid format.

Information to Disclose(Required):

This field is required.

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Most requests are for a specific conduct case; contact the DOS office for assistance if unsure.

Purpose of this Release(Required):

This field is required.

If applicable, case number:

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Case numbers are located on the top left of a written notice from the Dean of Students Office

Requester's Information

Complete the following sections of this form in its entirety:

Full Name

Select Role

Student ID Number

DOB (YYYY-MM-DD)

Phone Number

Email Address

Questions

In the text box below, provide the recipient's first and last name, recipient's title or relationship to student, name of agency or institution (if applicable), address, phone number, email, and reason for the release of information to a third party.

If the recipient is a potential employer, specific institution or agency, a physical address is required. Summary statements are not considered letters of recommendation and after processing, the forms are sent directly to the entity – NOT to students.(Required) This field is required.

How long will this release, specific to the recipient identified above, remain in effect? Note: students involved in the conduct process, a one time release will remain in effect through the end of an appeal.(Required)

This release is a one-time release only. This release will remain in effect for one year from the date of my signature below, unless I revoke such consent in writing, which I may do so at any time.

This field is required.

Please describe the reason for the release of information to Self or the aforementioned third party.(Required) This field is required.

SIGNATURE. By signing below, I acknowledge that I understand that I am not required to release my records to anyone. I am freely giving my consent to release the information in the manner described above.(Required) This field is required.

Supporting Documentation

Students who are not currently on campus OR no longer have an active Davidson college email address may request an Authorization to Release Form from the Dean of Students Office at deanofstudents@davidson.edu and submit a notarized copy electronically through this form. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

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Requests to Disclose Information

Requester's Information

Questions

Supporting Documentation

Submission