SECURITY ON CAMPUS, INC. STUDENT PRIVACY RELEASE FORM
The federal Family Educational Rights and Privacy Act of 1974 (FERPA) prevents institutions of postsecondary education from disclosing personally identifiable information about you without your written consent. Therefore, Security On Campus, Inc. will need your signature on this waiver before further investigating your case, or intervening on your behalf.
Name ________________________________________________________________________
Address ______________________________________________________________________
City ____________________________ State __________________ ZIP __________________
Phone ___________________________ E-Mail ______________________________________
Student Identification/Social Security Number ________________________________________
School Name __________________________________________________________________
City ____________________________ State __________________ ZIP __________________
I hereby authorize the release of any and all educational or other records pertaining to me in any way, or personally identifiable information contained in such records, by the above named educational institution to Security On Campus, Inc., or their employees or agents, for the purpose of reviewing the institution's response to reported criminal activity, or other alleged misconduct, and for the purpose of representing my interests relative to any such activity or misconduct.
Signature _______________________________________________ Date __________________
Please return completed, signed copies of this waiver to both your educational institution and to:
Security On Campus, Inc.
133 Ivy Lane, Suite 200
King Of Prussia, PA 19406-2101
TOLLFREE
1-888-251-7959
FAX (610) 768-0646
E-MAIL
soc@securityoncampus.org
http://www.securityoncampus.org/