The purpose of the Family Educational Rights and Privacy Act (FERPA) is to protect the privacy of information concerning individual students by placing certain restrictions on the disclosure of non-directory information contained in a student’s university records. I understand that I have the right not to consent to the release of my educational records and I have the right to receive a copy of such record upon request.
Name of Student: _____________________________________
I, the undersigned, hereby authorize the OISS at Utah State University to release the following education records and information (identify records or type of records): ______________________________
_____________________________________________________________________________________ to (Name and Address of Person / Agency to Receive Information) Valerio Calisiya___442 ½ E 400N APT1___________________________________________________ for the purpose of _________to pick up the OPT for me
I understand further that 1) I have the right not to consent to the release of my education records, 2) I have a right to receive a copy of such records upon request, 3) and that this consent shall remain in effect until revoked by me, in writing, and delivered to the OISS, but that any such revocation shall not affect disclosures previously made by OISS prior to the receipt of any such written revocation. ____Dongfang Yang_____________________________1/14/2013_______________________
This information is released subject to the confidentiality provisions of appropriate state and fereral laws and regulations which prohibit any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitter by such regulations.
Office of International Students and Scholars ( 0140 Old Main Hill, MS 115 ( Logan, UT 84322 T 435-797-1124 ( F 435-797-3522 ( www.usu.edu/oiss