PARENT DISCLOSURE FORM

PARENT DISCLOSURE FORM - FERPA

Please print clearly

Student Last Name:	__________________________________________
Student First Name:	__________________________________________
Student Clark ID#:	____________________

I/We hereby affirm that my/our son/daughter, currently enrolled at Clark University, is a dependent for tax purposes. I/We understand that Clark University may discuss grades and may disclose financial records and (in certain circumstances) other information concerning academic status, progress toward graduation, and extracurricular behavior to me/us.

Parent Name: _____________________________________________________

Address:

________________________________________________________

City:	________________________	State:	________________	Zip:	____________
Telephone:	(_____)____________________ Nation: _______________________

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Parent Signature: _________________________________________	Date:
Parent Signature: _________________________________________	Date:

PLEASE RETURN THIS FORM TO:

Registrar's Office

Clark University

950 Main Street

Worcester, MA 01610

fax # 508-793-7548