ࡱ> NPMO (bjbjrrrr 4$ee 8MijM(1K1K1KLLLLLLL$^ORFM1K[J1K1K1KM1$M L L L1K^L L1KL L L L_0KF LL:M0jM LZRK4ZR L LZRL1K1K L1K1K1K1K1KMM L1K1K1KjM1K1K1K1KZR1K1K1K1K1K1K1K1K1K : UNCP Department of Psychology FERPA Release Form Instructions for Students: There may be times when you want faculty members in the Department of Psychology to discuss your academic records with third parties. For instance, you may want a faculty member to discuss your academic records in a letter of recommendation for graduate school or in a telephone call or e-mail with a prospective employer. The Family Educational Rights and Privacy Act (FERPA) prohibits the release of certain information (including GPA, grades, and attendance) to third parties unless the student provides written consent to release his or her records. Thus, unless a signed copy of this form is on record with the Department of Psychology, faculty members will not write you a letter of recommendation or discuss your academic record with a potential employer. Instructions for Faculty: The Family Educational Rights and Privacy Act (FERPA) establishes certain rights for students regarding the privacy of their academic information. Namely, the release of non-directory information to third parties is prohibited unless the student provides written consent to release his or her records. Before writing a letter of recommendation for a student and/or discussing a students academic records with a potential employer, a signed copy of this form must be on file with the Department of Psychology. I, __________________________________ hereby request, give my permission, and direct the faculty of the University of North Carolina at Pembrokes Department of Psychology to discuss with and release the specified portions of my academic records to:  All prospective employers and/or academic institutions that contact the UNCP Department of Psychology. Or, to only the following prospective employers and/or academic institutions: _______________________________________ _______________________________________ Employer/Institution Reason for Information Release _______________________________________ _______________________________________ Employer/Institution Reason for Information Release _______________________________________ _______________________________________ Employer/Institution Reason for Information Release The following is the academic information that the Department of Psychology may release:  Attendance, grades earned, and performance in all courses; research activities if applicable Or, only the following academic information:  Attendance, grades earned, and performance in the following courses only: _________________________ Enter course numbers  Other (please specify): _________________________________________ In the case of a letter of recommendation:  I waive my right to review the letter I do not waive my right to review the letter Not applicable I understand and acknowledge that: (1) I have the right not to consent to the release of any of my education records; and (2) this consent shall remain in effect until revoked by me, in writing, and delivered to the UNCP Psychology Department, but that any such revocation shall not affect disclosures made prior to the receipt of any such written revocation. ______________________ ______________________ ______________________ First name Last name Banner ID Number ________________________________________________ ______________________ Signature Date Once you have completed this form, please return it to either a faculty member in the Department of Psychology or to the departments Administrative Support Associate. Please note that you will need to bring photo identification with you when you submit this form.     Approved by FERPA officer Sharon Kissick 11/13/12 Page  PAGE \* Arabic \* MERGEFORMAT 1 of  NUMPAGES \* Arabic \* MERGEFORMAT 2 0123Md n H I J K d e  C c d e f ^_abc#} `abʿηӳӳӥӞƳƚӚӚƚƚƳhp@h|hJ hxhxjhQUmHnHuhxhxhx6 hxhohC}ho ho6hhTDhwCJ aJ hCJ aJ hTDhCJ aJ hTDhTDCJ aJ 923J K d e f ac"#t89 &d P gdB`gdxgdx &d P gdgdogd$a$gdA:;<#$lgdk]gdBgdcn &d P gd`gdxgdxgdABG<.*, !"#%̼h6O5mHnHu h6O5jh6O5Uh6OhwjhwU hk]hxhk]hk]>*hC}hhk]hp@h^ hC}h hC}hBh>h5jhQUmHnHuhx5$%&'($a$gd6O dgd6Ogd%&'( hk]hxhwh21h:p6O/ =!"#.$% w666666666vvvvvvvvv666666>666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@6666OJQJ_HmH nH sH tH J`J pMNormal dCJ_HaJmH sH tH DA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List H`H  No SpacingCJ_HaJmH sH tH `P@` B Body Text 2dha$CJOJPJQJ^JaJP/P BBody Text 2 CharCJOJPJQJ^JaJ4"4 6O0Header  H$6/16 6O0 Header CharCJaJ4 @B4 6O0Footer  H$6/Q6 6O0 Footer CharCJaJRbR 6O0 Balloon Text dCJOJQJ^JaJN/qN 6O0Balloon Text CharCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VGRU1a$N% ʣꂣKЛjVkUDRKQj/dR*SxMPsʧJ5$4vq^WCʽ D{>̳`3REB=꽻Ut Qy@֐\.X7<:+& 0h @>nƭBVqu ѡ{5kP?O&Cנ Aw0kPo۵(h[5($=CVs]mY2zw`nKDC]j%KXK 'P@$I=Y%C%gx'$!V(ekڤք'Qt!x7xbJ7 o߼W_y|nʒ;Fido/_1z/L?>o_;9:33`=—S,FĔ觑@)R8elmEv|!ո/,Ә%qh|'1:`ij.̳u'k CZ^WcK0'E8S߱sˮdΙ`K}A"NșM1I/AeހQתGF@A~eh-QR9C 5 ~d"9 0exp<^!͸~J7䒜t L䈝c\)Ic8E&]Sf~@Aw?'r3Ȱ&2@7k}̬naWJ}N1XGVh`L%Z`=`VKb*X=z%"sI<&n| .qc:?7/N<Z*`]u-]e|aѸ¾|mH{m3CԚ .ÕnAr)[;-ݑ$$`:Ʊ>NVl%kv:Ns _OuCX=mO4m's߸d|0n;pt2e}:zOrgI( 'B='8\L`"Ǚ 4F+8JI$rՑVLvVxNN";fVYx-,JfV<+k>hP!aLfh:HHX WQXt,:JU{,Z BpB)sֻڙӇiE4(=U\.O. +x"aMB[F7x"ytѫиK-zz>F>75eo5C9Z%c7ܼ%6M2ˊ 9B" N "1(IzZ~>Yr]H+9pd\4n(Kg\V$=]B,lוDA=eX)Ly5ot e㈮bW3gp : j$/g*QjZTa!e9#i5*j5ö fE`514g{7vnO(^ ,j~V9;kvv"adV݊oTAn7jah+y^@ARhW.GMuO "/e5[s󿬅`Z'WfPt~f}kA'0z|>ܙ|Uw{@՘tAm'`4T֠2j ۣhvWwA9 ZNU+Awvhv36V`^PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!g theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] ($ %( ( Cegl!L  # @Q1 0(    # $Rectangle 2#"Ã?PK!8[Content_Types].xmlAN0EH%N@%邴K@`dOdlyLhoDX3'AL:*/@X*eRp208J妾)G,R}Q)=HiҺ0BL):T뢸WQDY;d]6O&8* VCLj"󃒝 yJ.;[wIC_ :{IOA !>Ø4 p;fɑ3׶Vc.ӵn(&poPK!8! _rels/.relsj0 }qN/k؊c[F232zQLZ%R6zPT]( LJ[ۑ̱j,Z˫fLV:*f"N.]m@= 7LuP[i?T;GI4Ew=}3b9`5YCƵkρؖ9#ۄo~e?zrPK!s;drs/e2oDoc.xmlSێ0}G,4UШjեi :Nba{m|=c[E< `dgְ̬ ռL9SNB]Wϟ/^qp0TUV z0BF .Ty"^Y&` hE$A15l:*#H|VmԜ|b>,+ϳ(剆ճҏn7(%6$Vkj/<«\ Y`=2Ԝ儥}$фb$CEYS߁MOY^H)Br]e4.Rm$ 17uL\I 􂨞.{ ˒Qs$\BSR2y0jcnc6?xfj\CL'# іT>'*5ٳղϳ3T'r<Ƒ~ly83oubYiܳ3_eD8IP5&+^*sn{ʦΎNdiBsoN۔VY?v~PK!drs/downrev.xmlLAO@&3fQEcK/P-a'=Nf2MY젎< *8KpW| 148a/) ʍ;ɎЪX">'.17[+7DMBSDXn&ɝK\h䧎l>=zIz{^c~{FX@^_~#:vx$ -YFȒ5PK-!8[Content_Types].xmlPK-!8! /_rels/.relsPK-!s;.drs/e2oDoc.xmlPK-!rdrs/downrev.xmlPKz   # $Rectangle 3#"Æ?PK!8[Content_Types].xmlAN0EH%N@%邴K@`dOdlyLhoDX3'AL:*/@X*eRp208J妾)G,R}Q)=HiҺ0BL):T뢸WQDY;d]6O&8* VCLj"󃒝 yJ.;[wIC_ :{IOA !>Ø4 p;fɑ3׶Vc.ӵn(&poPK!8! _rels/.relsj0 }qN/k؊c[F232zQLZ%R6zPT]( LJ[ۑ̱j,Z˫fLV:*f"N.]m@= 7LuP[i?T;GI4Ew=}3b9`5YCƵkρؖ9#ۄo~e?zrPK!.i;drs/e2oDoc.xmlSn0 }8Β1E XPd9&龾f{4Crq} h̙r5yꊳkj^|}&Ёi2q}ͻ}UAvʊ0[@+"-=[SL㋢l7486ö)ܙ!!־%ݣa)Lٖr;$neØ4 p;fɑ3׶Vc.ӵn(&poPK!8! _rels/.relsj0 }qN/k؊c[F232zQLZ%R6zPT]( LJ[ۑ̱j,Z˫fLV:*f"N.]m@= 7LuP[i?T;GI4Ew=}3b9`5YCƵkρؖ9#ۄo~e?zrPK!W;drs/e2oDoc.xmlSn0 }81E XPd9&ɾ~f{4Crqs h̙r5iꚳkj~T,_XR4 P]* ;eEW-\ Э)&U6Aˌ߶JƇ *2SsܤX.DE;-O4?B;z u'`;ԿAY-q$жZ\US^ZH2+?3ΜԢ$p[,PQ֓T` `QES!Re/~@W٦ ]ԡEIv 9IY^ :Q=_[%H3߇8>d`ٳdA4Te꬯|<1ߟ 4Fۚ_DT{)(lθIh"0qdt8izk*;GiLg'edsNT#gÊȱjK(7Q8,4V_ T]|}]4}"^? Tى=bq~*u,ry_PK-!8[Content_Types].xmlPK-!8! /_rels/.relsPK-!W;.drs/e2oDoc.xmlPK-! Xysdrs/downrev.xmlPK}  # $Rectangle 6#"Ç?PK!8[Content_Types].xmlAN0EH%N@%邴K@`dOdlyLhoDX3'AL:*/@X*eRp208J妾)G,R}Q)=HiҺ0BL):T뢸WQDY;d]6O&8* VCLj"󃒝 yJ.;[wIC_ :{IOA !>Ø4 p;fɑ3׶Vc.ӵn(&poPK!8! _rels/.relsj0 }qN/k؊c[F232zQLZ%R6zPT]( LJ[ۑ̱j,Z˫fLV:*f"N.]m@= 7LuP[i?T;GI4Ew=}3b9`5YCƵkρؖ9#ۄo~e?zrPK!;drs/e2oDoc.xmlSn0 }81E XPd9&~f{4Cry} h̙rv5iꊳkj^|}&Ёi2q}ͻ}UAvʊ0[@+"+=[SLy6A䫌߶J *2SsܦX-EC;-O4?B;z u+`{ԿAY-q$жZ\US^ZH2+?SΜԢ$p;>Eq oS9"LO_~2a*ȕWl$*wr@xX/Agϟ]PK-!8[Content_Types].xmlPK-!8! /_rels/.relsPK-!;.drs/e2oDoc.xmlPK-!n1eHtdrs/downrev.xmlPK~  # $Rectangle 7#"Ç?PK!8[Content_Types].xmlAN0EH%N@%邴K@`dOdlyLhoDX3'AL:*/@X*eRp208J妾)G,R}Q)=HiҺ0BL):T뢸WQDY;d]6O&8* VCLj"󃒝 yJ.;[wIC_ :{IOA !>Ø4 p;fɑ3׶Vc.ӵn(&poPK!8! _rels/.relsj0 }qN/k؊c[F232zQLZ%R6zPT]( LJ[ۑ̱j,Z˫fLV:*f"N.]m@= 7LuP[i?T;GI4Ew=}3b9`5YCƵkρؖ9#ۄo~e?zrPK!,*2;drs/e2oDoc.xmlSn0 }81E XPd9&ɾ~f{4Crq{ h̙r5iꆳkj~T._XR4 P]* ;eEW-\ Э)&U6Aˌ߶JmTd-Ig\jwZh`av^DvZ"hH-mTRS'ʵ8e V?" 3',#&(v}(?b*0_s(K!B)2?]HNlӿ.BVТM; Q$,dƙN/(,5G!!9%6&;ݬ X//ӌc}3wqau!7$kMQE`SuƝdL @s$ #YO[u'Pqf:ļNӸgg:eD8IP5 *+TQZMX҄ޜ)~;PK!$drs/downrev.xmlLN0DHHZE4S!P8&^xNz̉G3ym'ۉ3 ua ip,v'> ooo2L·PX>E M}*'ާ,(Z/vR%ɣr\hh5:ϾxKzSq?^7 M? T"^ r "J@VdkPK-!8[Content_Types].xmlPK-!8! /_rels/.relsPK-!,*2;.drs/e2oDoc.xmlPK-!$tdrs/downrev.xmlPK~  # $Rectangle 8#"Ê?PK!8[Content_Types].xmlAN0EH%N@%邴K@`dOdlyLhoDX3'AL:*/@X*eRp208J妾)G,R}Q)=HiҺ0BL):T뢸WQDY;d]6O&8* VCLj"󃒝 yJ.;[wIC_ :{IOA !>Ø4 p;fɑ3׶Vc.ӵn(&poPK!8! _rels/.relsj0 }qN/k؊c[F232zQLZ%R6zPT]( LJ[ۑ̱j,Z˫fLV:*f"N.]m@= 7LuP[i?T;GI4Ew=}3b9`5YCƵkρؖ9#ۄo~e?zrPK!/~;drs/e2oDoc.xmlSn0 }8.1E XPd9&ɾ~f{4C` + \ј3$4mk՜kj~T,_}&Ёi2q}ͻ}UAvʊ0[@+"-=[SL㫢lhmb$OCEYOS߃UGYNH)Br]e=4.vRm$ !7xn:D&gyU.&3$NvzATϗ=Veɨ9 .!)<ݬ1fe:?xfkC'# Ѷsjo\C4E6Mw1)7t`͑TD&6g=Moם@řyr:M㞝l.#Iyl0WqXG2lD&4Mi.cPK! a drs/downrev.xmlLN0DHHܨ6S!P8酛/IJb |=Tyyogӳ3$!Z`H5ayEZP7:7ʴ߰PB.SZsWh[)dv4ʇsl%BܨB|i:LFBG/߄Y>Uy0u(Se'Ҏ4J*!^ Y=E* b _PK-!8[Content_Types].xmlPK-!8! /_rels/.relsPK-!/~;.drs/e2oDoc.xmlPK-! a tdrs/downrev.xmlPK  # $Rectangle 9#"È?PK!8[Content_Types].xmlAN0EH%N@%邴K@`dOdlyLhoDX3'AL:*/@X*eRp208J妾)G,R}Q)=HiҺ0BL):T뢸WQDY;d]6O&8* VCLj"󃒝 yJ.;[wIC_ :{IOA !>Ø4 p;fɑ3׶Vc.ӵn(&poPK!8! _rels/.relsj0 }qN/k؊c[F232zQLZ%R6zPT]( LJ[ۑ̱j,Z˫fLV:*f"N.]m@= 7LuP[i?T;GI4Ew=}3b9`5YCƵkρؖ9#ۄo~e?zrPK!Ʀѻ;drs/e2oDoc.xmlSێ0}G,4]QժK+>`8oݦ;R.k&3>>sffqs0%lј3ikkBۀvV(Y>}%'sĆ5bUQIa伴lhzB7WE Am+EжAFkNb>1tT[)q€"ߠkH8SUBrK5xk!q?x@̂}$nd$OCEYS;%0Ve[Dw"U tmw!tE:h i!sC!2A?˫r>q&(t P=] KF͑gp߇8>dNf7+l4Te|<1ߟ 4Z_J ф*҃Mi{1)7t`#n`82:8izk%gN4{vWr2U`";jKeݺ[^Yܛ6s֏_~PK!"2 drs/downrev.xmlLN@&fLZ1xl]Z]Oz|q īƪ޴jw<E5EAg"BK階5لۻ4NTCdEk7CG#?u|fPɑKݭ]jy|y0u(Smg8 (Bf adY PK-!8[Content_Types].xmlPK-!8! /_rels/.relsPK-!Ʀѻ;.drs/e2oDoc.xmlPK-!"2 sdrs/downrev.xmlPKB S  ?a A (ttt tt tt#&)&)#)> (xI ^ O&Yq4p@>Pk]cn%tw|pMJRRX oBC}'%6OnQTD57^wb!>:@(@UnknownG.[x Times New Roman5Symbol3. .[x Arial7..{$ CalibriI Arial Unicode MS5. .[`)TahomaC.,.{$ Calibri LightA$BCambria Math"hRb'Rb',b ,b !nr0CHP  $P2!xx UNCP Daisy Long Oh+'0X    ,8@HPUNCPNormal Daisy Long2Microsoft Office Word@@s@s,b  ՜.+,0 hp  UNCP  Title  !"#$%&'()*+,-./0123456789:;<>?@ABCDFGHIJKLORoot Entry FJ0Q1TableZRWordDocument4$SummaryInformation(=DocumentSummaryInformation8ECompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q