Authorization For Release Of Protected Education Information Form - State Of Rhode Island And Providence Plantations Family Court Page 2

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I have carefully read the above information and I voluntarily consent to disclosure of the indicated
confidential educational records of my child ___________________________________. I understand
that my child’s records are protected under state and federal law and cannot be disclosed without my
written consent unless otherwise provided for in the law. I understand that if I authorize the Rhode
Island Family Court Mental Health Clinic to receive information from my child’s school, the Clinic
will not disclose it to others. I also understand that I may withdraw or revoke this consent in writing at
any time and no further records will be released after that. I understand that my child’s records are
protected from release without my permission by the Family Educational Rights and Privacy Act
(FERPA) (20 U.S.C. § 1232g) and the Rhode Island Educational Records Bill of Rights (G.L. 1956
§ 16-71-1 through § 16-71-5).
The Rhode Island Educational Records Bill of Rights gives me and my child:
“ The right to have the records kept confidential and not released to any other individual,
agency or organization without prior written consent of the parent, legal guardian, or
eligible student, except to the extent that the release of the records is authorized by the
provisions of 20 U.S.C. § 1232g or other applicable Rhode Island law or court process or
procedures.
This release expires automatically one (1) year from the date signed.
Parent Signature: ________________________________________ Date: _____________________
OR
Legal Guardian Signature: ________________________________ Date: _____________________
Relationship to Student: _____________________________________________________________
Witness Signature: _______________________________________ Date: _____________________
Page 2 of 2
FC-16 (revised January 2012)

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