Consent for Release of Information

First Name

Last Name

University ID

Birthdate

Email

What is your current status?

Read this important information before filling out this form

The federal Family Educational Rights and Privacy Act of 1972 (FERPA) protects the privacy of students’ education records. You also may have rights under the laws of the United States, the State of Tennessee and/or your country of residence protecting the privacy of your records.

By completing this form, you hereby waive any rights described above and give consent to the emergency contacts listed in this form to obtain your records include, but is not limited to, academic, medical, administrative, judicial, or insurance. You also grant authorization for the contacts listed in this form to represent your interests in meetings and communication with the University of Memphis (UofM) in the event of an emergency.

You have the right not to consent to the release of information. You may also revoke the consent or update this consent form at any time by giving written notice to the International Student Services team. If you do not want to give consent or need to revoke/update the consent form, please email TheWorld@memphis.edu.

This consent is effective as of the submission date and remains valid until revoked in writing.

Emergency Contacts in the United States

Please provide the information of an individual living in the U.S.

First Name

Last Name

Address

Country

Street

City

Region

Postal Code

Phone Number

Email Address

Relationship

Would you like to add a second contact living in the U.S.?

Yes

No

Please provide the information of a second individual living in the U.S.

First Name

Last Name

Address

Country

Street

City

Region

Postal Code

Phone Number

Email Address

Relationship

Emergency Contact in Home Country

Please provide the information of an individual living in your home country.

First Name

Last Name

Address

Country

Street

City

Region

Postal Code

Phone Number

Email Address

Relationship

Would you like to add a second contact living in your home country?

Yes

No

Please provide the information of a second individual living in your home country.

First Name

Last Name

Address

Country

Street

City

Region

Postal Code

Phone Number

Email Address

Relationship

Acknowledgements and Consent

By signing below, I understand that:

International Student Services team will notify the contacts listed in the event of an emergency.
It is my responsibility to promptly update any information that may change in this form to ensure accurate communication in the event of an emergency.
It is my responsibility to ensure the contacts listed are able and willing to act in the event of an emergency.
I have the right not to consent to the release of information.
I may revoke the consent or update this consent form at any time, provided I submit a written notice to the International Student Services team. Any updates or changes will take effect once recorded.
I am authorizing disclosure of information protected under federal law. This information, once disclosed, may be subject to re-disclosure by the recipient and may no longer be protected by state and federal law.
A copy of this document shall have the same effect as the original of same.

By typing your name in the field below, you acknowledge that this will serve as your electronic signature, and it holds the same legal effect as a handwritten signature.