Permission-to-release-confidential-data

Registry Services Queens Road, Richmond, TW10 6JP, UK Tel +44 (0)20 8332 8201 Email: registryservices@richmond.ac.uk Permission to Release Confidential Data Section - University Policy on Data Release In accordance with the UK Data Protection Act 2003 (DPA) and The USA Family Educational Rights Privacy Act 1974 (FERPA), Richmond, The American International University in London (hereafter referred to as Richmond) is required to protect the personal data it holds about its registered students As a result of these Acts of Law, Richmond is required to obtain your written permission to disclose information to any third party from any part of your student educational records with the exception of those institutions listed within the Acts This means that response by Richmond to requests for information from parents, guardians, sponsors, potential and actual employers and any other institution or person not included in the Acts as exempt must be agreed by you in writing This form allows you to give that permission in general (if you wish) rather than having to agree in each specific case Section - Consent to Release Information Instructions and Declaration To the Student Please be aware that: This form gives permission for your personal data held by the University data to be released to those named on the form If you not wish to have your data released please select the final option on page in the “choice of data to be released” section Richmond will only release the specific data selected in section 3 You can revoke your permission to share data at any time by submitting another “Permission to Release Confidential Data” Form and selecting the final option on page This form does not replace the Transcript Request Form If you wish to order an academic transcript please visit www.richmond.ac.uk for a copy of the Transcript Request Form and submit it to Registry Services Please sign before continuing: I have read and understood the policy of Richmond, The American International University in London on the release of personal data Signature: Name: (please print) Date: Now complete the information on page Permission to Release Confidential Data page Section - Permission to Release Confidential Information - Details Below are choices for the types of data that can be released from your records Please select the options required  Academic Data (including that received from prior institutions)  Financial Data  Admissions Data  Social and Housing Data  Advisor Data  I not wish to release any of my data Third Party Details (to whom this information should be released): Name: _Title: Company Name (if Applicable): Contact Address: _ Telephone Number E-mail Address: Student Declaration (PERMISSION to Release Data): Please release my personal data requested by the above named person or company I am fully aware of the nature of their request and have no objection to my data being released Name: Signature: Date: Student ID Number: _ Student Declaration (REFUSAL to Release Data): I not wish to have my personal data released without my specific written permission Name: Signature: Date Student ID Number: _ Registry Services August 2018