ࡱ> 02/  bjbjss 1 \\\\\pppp |p333(******$S"N\3!333N\\c3\\(3(x: I"y0,"kF""\83333333NNF3333333"333333333 ": ϳԹUniversity Upward Bound FERPA Form for Higher Education Institutions To: (Name of University Official and Department that will be releasing the educational records) From: __________________________________________________________________ Students First Name Middle Initial Last Name __________________________________________________________________ Permanent Street Address City State Zip Code Under the Family Educational Rights and Privacy Act (FERPA), the [Postsecondary Institution] is permitted to disclose information from your education records to the ϳԹUniversity Upward Bound Program, if you participated in the Upward Bound Program. Please indicate whether you participated in the ϳԹUniversity Upward Bound Program. Please check the appropriate box: Yes. I certify that I participated in the ϳԹUniversity Upward Bound Program from DATE: / / to : / / Yes. I give permission to obtain the following information from my institutional records during the following dates Please check a information you consent to having disclosed to the ϳԹUniversity Upward Bound Program: Enrollment verification Academic Transcripts Graduation confirmation Financial Aid records Signature: _________________________________ Date: ______________ I understand the information may be released orally or in the form of copies of written records, as preferred by the requester. I have a right to inspect any written records released pursuant to this Consent (except for parents financial records and certain letters of recommendation for which the student waived inspection rights). I understand I may revoke this Consent upon providing written notice to [Name of Person listed above as the University Official permitted to release the educational records]. I further understand that until this revocation is made, this consent shall remain in effect and my educational records will continue to be provided to [Name of Person listed above to whom the educational records will be released] for the specific purpose described above. !MQRX \ u   3 R + D P [ q s t u | [ \ ] t u v  ƻưhwh7YTCJaJhB3 h;bu5h;buh;bu5jh;buUmHnHuhwhwCJaJhw5CJ\aJhwhw5CJ\aJhwjhwUmHnHujh%UmHnHuh7YTh%h;bu2NOPQX2 3 x r s t d^gdB3gd;buh^h & F ^`gd% \ u d^`gd% 8d^gdB3 / 01h/ =!"#$% ^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List 6>@6 Title$a$ 5CJ\H@H | Balloon TextCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] )    8 @H (  B  3 1B  3 1B   3 jJB   3 jJB   3 jJB   3 jJB  3 jJB  3 16   B S  ?      Q\u Jd#t #tt $$tB $$t 7t 7t 7t7t  33    gc,>4808^8`0OJPJQJ^Jo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(gc,>>p&         @ @7YT;buw|%sB3d  @u H@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial5. .[`)Tahoma?= *Cx Courier New;WingdingsA$BCambria Math"q h;q';q';q'YY!x24 3QHP ?|2!xx DModel Form for Disclosure to Parents of Dependent Students (MS WORD)U.S. Department of Educationebaker03 Oh+'0 $0 P \ h tHModel Form for Disclosure to Parents of Dependent Students (MS WORD) U.S. Department of EducationNormal ebaker033Microsoft Office Word@ @PV@ \2@ܥY՜.+,0H hp  ) U.S. Department of Education  EModel Form for Disclosure to Parents of Dependent Students (MS WORD) Title  !"#$%&()*+,-.1Root Entry F31Table #WordDocument1SummaryInformation(DocumentSummaryInformation8'CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q