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.

Based on this affidavit I/we request that Clark University use the following address for semester billing statements. Fall semester bills are issued in late June and Spring semester bills are issued in November. Statements issued during the semester will be sent to the student's campus address.

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