Student Consent for

Release of Information
The Family Educational Rights and Privacy Act (FERPA)
FERPA gives registered students the right to inspect and review their “educational records.” “Educational records” are records, files,
documents, and other material regularly maintained by the university and directly related to the student. It specifically excludes:
• Directory information
• Records maintained personally by university personnel, which are not available to others
• Medical and counseling records
• Some law enforcement/legal records
• Financial information about your parents
The Act also states that the university cannot permit access to, or release of, “educational records,” or personally identifiable information
contained therein, to any party without the consent of the student. There are exceptions, for example, for directory information and
information disclosed for legitimate educational purposes. (See The Concordia University, Nebraska Student Handbook for a full
explanation of the FERPA policy.)
To comply with FERPA, students must provide written consent to the university to release “educational records,” even to a student’s
parent or guardian. By signing the statement below, you are authorizing representatives of Concordia University to release, to the
individual specifically identified below, your entire “educational record” including, but not limited to:
• Academic (grades, class schedule, progress reports, attendance, etc.)
• Financial (student financial account, financial aid, scholarships, etc.)
• Discipline/Social (formal/informal discipline, personal well being, behavior, social interactions, etc.)

I, _________________________________________, (student name) authorize representatives of Concordia

University to release FERPA educational records and student information (academic, financial, or discipline/
social affairs) to parent/legal guardian/individual(s) listed below.

___________________________________________ ___________________________________________
Student Signature Date
___________________________________________
Student ID J#

OR I don’t want anyone to know my information that is listed above

Information may be provided to:

___________________________________________ ___________________________________________
Name (please print full name) Name (please print full name)
___________________________________________ ___________________________________________
Address Address
___________________________________________ ___________________________________________
City State ZIP City State ZIP
___________________________________________ ___________________________________________
Email Email
___________________________________________ ___________________________________________
Cell Phone Cell Phone

ATTENTION: This release allows for release of information, but does not guarantee or require Concordia University, Nebraska to
initiate disclosure of any information regarding the student.

If you intentionally leave this form blank your parent/guardian WILL NOT be able to call and get information on your bill. Financial
account, academics, or discipline/social interactions.
Residence Hall Contract
FOR OFFICE USE ONLY
Date Received _________
Room _________________

New Student Returning Student Transfer Student Other

Spring Fall Year 20 _________
If living off campus: Please do not complete this form. Instead contact [email protected].

Name ____________________________________________________________ Student ID J# ___________________________

First M. Last
Address ________________________________________________________________________________________________
Street City State ZIP
Birth Date ______________ Age _______Phone(Cell) _________________Email ______________________________________
Male Female Unmarried Married Divorced

Parent/Guardian ________________________________________Phone (Home) ________________(Cell)_________________

First M. Last
Address ________________________________________________________________________________________________
Street City State ZIP
Roommate Preference(s)
If you do not list a name the Housing Coordinator will assign roommates according to the attributes listed below. If you know who you
would like to room with, you must BOTH request each other as roommates at the time of application in order for the request to be
considered. Typically, we do not have space available for first year students to request a paid private room. Please provide the name(s)
of all requested roommate(s) here, if applicable:
___________________________________________ ___________________________________________
Activities I will be involved in: Varsity Athletics (the coach knows you’re coming) Sport: ____
___________________________
If yes, would you prefer to live with a teammate, if possible? Yes No No preference
Art, Music, Theatre, Forensics, etc. Activity: ____
____________________________________

My academic area of study will be ____________________________________________________________________________

Three words that describe me are _________________________ _________________________ _______________________

Do you smoke? Yes No Would you room with someone who smokes? Yes No
For the following statements, choose the answer that best describes you:
If there are clothes all over the floor
In the morning, I tend to
At night, I tend to
I prefer to room with someone
Once I get to know my roommate, I
I tend to be
Music listening preferences Country Hip Hop Alternative Pop
Christian Hard Rock Other
The main reason(s) I am coming to Concordia University, Nebraska is: ________________________________________________
What is most important to you in your college experience? _________________________________________________________
Please indicate any allergies you have (including animals): ________________________________________________________
Other factors affecting room assignment: _______________________________________________________________________
If you have any medical or health related concern that could impact housing please contact [email protected] as soon as possible.
Other preferences: _________________________________________________________________________________________

If Student is under 19 years of age by the first day of the semester for which housing is requested, the student’s parent or guardian must sign below:
_______________________________________________________________________________________________________
PARENT OR GUARDIAN SIGNATURE, SURETY TO CONTRACT PERFORMANCE

I hereby acknowledge that I have read and understand the terms as set forth above and on the Residence Hall Terms and Conditions
page, and I understand that I am obligated to abide by all aspects of this agreement.
_______________________________________________________________________________________________________
STUDENT SIGNATURE
Residence Hall Contract
Terms and Conditions
1. ROOMMATE ASSIGNMENT: While every effort will be made to comply with the student preferences of residence hall assignment and roommate
choice, final determination is made by the university.
2. VACATING RESIDENCE HALL: In the event a resident vacates a room, the remaining resident may be assigned a new roommate or be
reassigned to another room as determined necessary by the Housing Coordinator in the Student Life Office. If a resident requests to have a single
room, the additional private room charge will be assessed, pending availability.
3. Room or roommate changes must follow the guidelines outlined in the Student Handbook. There may be a $100 minimum* processing fee for
all student-initiated modification of signed Residence Housing Contract resulting in change of resident hall room/roommate.
4. Factors of race, color, or national origin will not be considered in making room assignments; requests for specifically named roommates must
be reciprocal in nature and received prior to the time a room assignment is made by the Housing Coordinator.
5. Residence Hall Contracts are for the 1st and 2nd semesters of the academic year, unless otherwise indicated on the contract. This contract
does not provide room and board during officially designated vacation periods. See Student Handbook Calendar for those dates. There will be a
$50/night minimum* occupancy fee for approved occupancy of the residence hall room outside the housing contract dates and outside of school-
sponsored events.
6. TOBACCO AND PET FREE: Concordia University has tobacco and pet free residence halls and dorm rooms. No tobacco use is allowed in the
residence halls, no pets allowed.
7. CLEANLINESS/DAMAGE: Every resident is responsible for the cleanliness and maintenance of his or her room and is liable for any damage to
residence hall property or furnishings in his or her room resulting from abuse or lack of care.
8. PRIVACY & INSPECTIONS: During the course of the year Student Life Office personnel will conduct periodic HEALTH AND SAFETY
INSPECTIONS for fire, health, safety, and security purposes. These will be conducted as scheduled monthly, during vacations (Thanksgiving,
Christmas and Spring Break) and when circumstances necessitate for the health and safety of students. Additionally, the Student Life Office staff,
Residence Hall Coordinators and Resident Assistants have the privilege of entering any residence hall room if there is “reasonable cause” to believe
a University code or policy is being violated. Failure by a resident/student to give access to a residence hall room when requested to do so by a
University official is a violation of policy. (See Student Handbook for further clarification on access, fire safety, maintenance, inspections, privacy
and visitation.)
9. GUESTS: Residents are responsible for their guests and are accountable for complying with guidelines as stated in the “Guests” section of the
Student Handbook.
10. UNCLAIMED BELONGINGS: Personal effects, valuables or other property of the resident in the residence hall at the close of the current
academic year and not reclaimed within 30 days thereafter may be detained or disposed of by the university.
11. TERMINATION OF CONTRACT: Conduct deemed to be such as to require removal of the student from the residence halls shall be grounds
for termination of the Residence Hall Contract. The University may terminate this agreement and take possession of the room or re-assign the
resident(s) to another room or residence hall for consistent violation of any university regulation as found in the Student Handbook or this contract,
for health or social reasons, or for any reason deemed sufficient by the Student Life Office.
12. BREACH OF HOUSING CONTRACT: There is a $200-$500 minimum* fine for a breach of signed Residence Housing Contract. Failure
to notify SLO by JUNE 1 of plans to live off campus (after turning in a signed Residence Housing Contract) is considered a Breach of Housing
Contract.
13. WITHDRAWAL FROM UNIVERSITY (ATTRITION): Students who sever connections with Concordia for reasons other than graduation
MUST BE ATTRITIONED. They MUST complete the attrition form prior to leaving campus. This form can be obtained from the Student
Services office. The residential student must also complete the room check-out process with the Resident Assistant. Upon completion of the
Attrition Form and room check-out process, the refund of the unexpired portion of the room and board, if any,
will be made.
14. CHECK-OUT PROCESS: When a student living in the residence halls graduates, attritions, or moves to an off-campus residence, the
student must complete the residence hall check-out process with the Resident Assistant. Damages noted on the check-out form, if any, will be
documented and processed by the Buildings and Grounds Department to determine costs for repair or replacement charged to the student.
Failure to officially check out results in a minimum $50.00 fine.
15.MEAL PLANS: Students living in the residence halls are automatically charged for the unlimited meal plan at the dining hall. Any changes to
this meal plan must be made by August 26, 2022 (fall semester) and January 13, 2023 (spring semester) by completing a Meal Plan Change Form
in the Student Life Office.

*Additional charges may be added when a student fails to provide timely notification to SLO, obtain SLO approval, or follow SLO guidelines, policy, protocol or process.
Emergency
Contact Information
This information may be shared with your RA, RC, Security and the Student Life Office.
Name__________________________________________________________________________________________________
Last First
Student’s Cell Number ___________________________________________ J# _____________________________________

Emergency Contact #1
Name ____________________________________________ Relationship__________________________________________
Address ________________________________________________________________________________________________
Street City State ZIP
Best Phone Number ______________________________________________________________________________________

Emergency Contact #2
Name ____________________________________________ Relationship__________________________________________
Address ________________________________________________________________________________________________
Street City State ZIP
Best Phone Number ______________________________________________________________________________________

Medical Information that the Student Life Office should be made aware of:
Medical Condition(s):
______________________________________________________________________________________________________
Medication(s)/Location(s):
______________________________________________________________________________________________________
Allergies:
______________________________________________________________________________________________________

Missing Person Contact

Name _________________________________________________________________________________________________
Best Phone Number ______________________________________________________________________________________

Signed: _____________________________________________ Date: _____________________________________________