e-Learning Address & Consent for Release of Information Form

The Family Education Rights and Privacy Act (FERPA) of 1974 with amendments, was established to protect the privacy of student education resources. Except as allowed and required by law, no personally identifiable information from a student's record should be disclosed to any third party (e.g., parent, spouse, other students) without prior written consent of the student. e-Learning students usually communicate with their instructor, the e-Learning Office and the college in ways other than face-to-face. The purpose of this form is to obtain permission from you to answer inquiries for you about the e-Learning course you indicate below over the telephone, by voice mail, answering machine, U.S. Mail, email or other methods of communication that could possibly be defined as or used by a third party. This form will be provided to your instructor and a copy kept in the e-Learning Office.

Course:		Semester:	Year
*First Name:		*Last Name:
*Address:		*City:	*State:	*Zip Code:
Home Phone:	(home)	Best time to call: Enter "none" if you do not have a phone
Work Phone:	(work)	Best time to call: Enter "none" if you do not wish calls at work
*Email:

I hereby authorize my instructor and the e-Learning Office to communicate all relevant information with me for the above course / semester using the above information.

	I attended a start-up session with the instructor.
	I attended a start-up session online via Blackboard
	I am willing to share some contact information with other class members.
*	By checking this box I certify that I am the person named on this from and therefore, to the best of my knowledge all information is accurate. If you do not wish to submit this electronically, you MUST* come to the e-Learning Office (CM2124) to complete this form.
*Student ID Number:				May 18, 2013