Skip Navigation
small NCES header image
Forum Guide to Protecting the Privacy of Student Information: State and Local Education Agencies

Left ArrowReturn to List of Exhibits and Figures

Exhibit 5–4: Sample Consent Form to Allow Accompanying Person to Review Record

(For Use by Parent or Eligible Student to Grant Consent)

I hereby grant permission for [name of person] _________________________ to accompany me today during my review of my/my child’s education records. I understand that in doing so, the information maintained in the education records, otherwise protected by the Family Educational Rights and Privacy Act (FERPA) [and state laws, if applicable], may be disclosed with my consent to the above individual.


Name: _________________________

Date: _________________________

For Use by Accompanying Person as Affidavit of Nondisclosure

In accompanying the above-signed parent/guardian on this date during his/her review of the education records of: _____________________, I will be given access to confidential information maintained in the records of the named student. I understand that this information is protected under FERPA [and state laws, where applicable]. I hereby acknowledge that I fully understand that the intentional release by me of this information to any unauthorized person could subject me to [penalties, where applicable] imposed by FERPA [and state laws].

Signature: _____________________

Name: _________________________

Date: _________________________

For Official Use Only

Staff Initials: ______________________

Date: ______________________

Left ArrowReturn to List of Exhibits and Figures


Would you like to help us improve our products and website by taking a short survey?

YES, I would like to take the survey


No Thanks

The survey consists of a few short questions and takes less than one minute to complete.
National Center for Education Statistics -
U.S. Department of Education