Instructions to Student: Carefully read the information below. If you have questions about the intended use of the student information or student creative work, please ask the faculty or staff member before signing. Your decision to grant permission or to deny permission will not have any impact on your grade in the related course/service program.

I, _____________________________ [enter student’s name], pursuant to FERPA1, hereby give my written consent and permission to _______________________________ [enter the name of faculty/staff] at ________________________[enter the name of institution] to release and/or use my written assignments, essays, papers, and other written materials created and/or prepared by me and submitted in connection with _____________________________________________[enter course identifier and name] or entitled [enter the specific name of paper or project or other creative work as necessary] _________________________________________________________________

as part of the College’s internal self-evaluation and/or assessment procedures, or internal to the College’s efforts to improve teaching and learning effectiveness or experiences or to recognize student achievement. This includes permission to duplicate and/or disseminate a reasonable number of copies of my paper/work to other parties on campus.

____ Please remove my name and identification number from any duplicated copies

____ My name may be displayed on any duplicated copies

I understand that my written consent will remain in effect until I notify the employee/office named in this form, in writing, to cancel it.

I understand that the specific information referenced on this form may be released to third parties on campus with my consent/permission with the understanding that s/he will not release it to any parties external to the specific institution listed.

____________________________ [student signature]

____________________________ [date]

Family Educational Rights and Privacy Act (FERPA) of 1974 20 USC § 1232g and 34 CFR § 99 requires The Claremont Colleges to obtain written consent from a student before releasing the educational records of that student to a third party and includes the student’s “creative work” developed in response to course requirements.