Sample Disclosure Consent Form

A student's consent to disclose information from education records must specify the records to be disclosed, the party or class of parties to whom the university may disclose the records, and the purpose of the disclosure. A student may consent electronically, including by e-mail.

A disclosure in this format would meet the requirement:

I, [student name], authorize the University of California, San Francisco to disclose [specify records] to [specify party or class of parties] for [state the purpose].

[Student Name]

[Student Signature]

[Date]

A Word template is also available.