OFFICE OF STUDENT CONDUCT

RELEASE OF INFORMATION AUTHORIZATION – WITNESS

Created: 03/29/2017

901 S. National Avenue ▪ Springfield, MO 65897

Student Name: BearPass #: M

LAST FIRST MI

Missouri State University (the “University”) complies with the Family Educational Rights and Privacy Act, 20

U.S.C. § 1232g (“FERPA”) and FERPA’s implementing regulations, 34 C.F.R. § 99.1, et seq. Subject to certain exceptions, the University does not disclose a student’s educational records and information to others without the student’s written authorization. Students may sign this Release of Information Authorization Form to authorize the University to disclose the students’ records and information subject to the law, applicable policies, and the parameters and restrictions set forth below.

Information about the University’s FERPA compliance is available on the University’s website at: www.missouristate.edu/registrar/FERPA.html. I recognize that records are maintained at various offices throughout campus, and therefore understand that I will need to submit a separate request to each relevant office.

By signing this form, I hereby allow the University’s Office of Student Conduct to release my name in connection with the Office of Student Conduct’s disciplinary action/disciplinary proceeding identified below.

Office of Student Conduct Disciplinary Action / Proceeding: ______

By signing this release, I understand that the Office of Student Conduct will release my name as a witness in this matter to participants in the Student Conduct action and/or proceeding. These individuals may include, but are not limited to: the respondent and complainant students, conduct advisors, hearing panel members, and designated appellate authorities.

This authorization may be revoked in writing by delivering a written revocation to the Office of Student Conduct. However, I recognize that any delayed revocation may result in my information being released prior to receipt of my revocation. Absent any revocation, this authorization will remain in effect for the duration of the above referenced disciplinary action / proceedings, including any appeal pursuant to the University’s Code of Student Rights and Responsibilities.

Student Signature: Date:

OFFICE USE ONLY:

Processed By Date