Consent to Release Form

Full Name: _______________________________________________

I, ____________________________, hereby authorize the University of Oregon to release job reference information, including the dates of employment, job duties, and quality of my performance to any prospective employers who request the information for hiring purposes.

I understand that this information is considered a student record. Further, I understand that by signing this release, I am waiving my right to keep this information confidential from the above personnel under the Family Educational Rights and Privacy Act (FERPA).

I certify that my consent for the release of this information is entirely voluntary. I certify that I understand this consent to release can be revoked by me at any time in writing but will not be effective for materials already released under it.

Student Signature: ____________________________ Date: _____________

Signed release forms should be submitted to the supervisor or department that employed the student and retained in the department office.