Authorization For Release Of Medical And Educational Information And Records (Page 3 of 3) in pdf

Authorization For Release Of Medical And Educational Information And Records Page 3

Family Educational Rights and Privacy Act and may only be disclosed as permitted by

that Act. I further understand that I may request a copy of this signed Authorization.

Signature: ____________________________________________

Date:_______________

Relationship to Student (circle one):

Parent

Legal Guardian

Student (if age 18)

Authorization for Release of Education Records

Please initial next to each paragraph below in order to allow the exchange of the student education

records described on page one (1) between South Bend Community School Corporation and the

Agency listed above under the Family Educational Rights and Privacy Act.

Initial Below

__________ I understand that I have the right not to consent to the release of my child’s educational

records.

__________ I understand that I have the right to receive a copy of such records upon written request

to the South Bend Community School Corporation.

__________ I understand that if I give permission, I have the right to change my mind and revoke it.

The revocation must be in writing and delivered to the South Bend Community School

Corporation. I also understand that such revocation will not affect any uses or

disclosures already made with my permission.

__________ I understand that unless otherwise revoked by me, this authorization will expire on the

following date, event, or condition. If I fail to specify an expiration date, event, or

condition, this authorization will expire one year from the signature date.

One year after the student is no longer enrolled in a SBCSC school

□

Other: __________________________________________________

□

Please specify expiration date, event, or condition

Signature: ____________________________________________

Date:_______________

Relationship to Student (circle one):

Parent

Legal Guardian

Student (if age 18)

THIS INFORMATION IS RELEASED SUBJECT TO THE CONFIDENTIALITY PROVISIONS OF THE FAMILY

EDUCATION RIGHTS PRIVACY ACT (FERPA) AND OTHER APPROPRIATE STATE AND FEDERAL LAWS AND

REGULATIONS WHICH PROHIBIT DISCLOSURE OF EDUCATIONAL INFORMATION WITHOUT THE SPECIFIC

WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS, OR AS OTHERWISE PERMITTED

9/19/14

Authorization For Release Of Medical And Educational Information And Records Page 3