West Virginia School of Osteopathic Medicine

FERPA Release Form for Financial Aid Information

The West Virginia School of Osteopathic Medicine, by its participation in federal student aid programs, is required to follow the guidelines set forth in the Family Educational Rights and Privacy Act (FERPA). This act mandates that we safeguard and maintain the privacy and confidentiality of all student records. If you have a person or organization to whom you want information released you must complete this form.

Student Name: _________________________________   Social Security Number: _________________

Home Phone: ____________________________   Alternate Phone: _____________________________

Address:______________________________________________________

City, State, Zip:_________________________________________________

By completing the list and signing below, you give us permission to discuss your student records with someone other than yourself (i.e. spouse, parent, scholarship organization).

 I hereby authorize the West Virginia School of Osteopathic Medicine Financial Aid Office to release financial information about me to the person(s) listed below: 

In the event you wish to cancel this release, you must do so in writing with the Financial Aid Office. The West Virginia School of Osteopathic Medicine will not be responsible for disclosure of information made before written cancellation is received by the Financial Aid Office.

Student’s Signature: __________________________________    Class of ___________________

ORIGINAL SIGNATURE REQUIRED

Date: ______________________________

Please return to:

West Virginia School of Osteopathic Medicine
Financial Aid Office
400 North Lee Street
Lewisburg, WV 24901