Education Public Private Document

Education Public Private Document

Student Information

Date of Birth:    Student ID:

Primary Phone:    Email:

Parent / Guardian Information

Relationship to Student:    Phone:

Current School Information

School Type: Public Private    Address:

Current Enrollment Start Date:

Receiving / Prospective School

School Type: Public Private    Address:

Intended Start Date at Receiving School:

Purpose and Requests

Purpose of this Document (select all that apply):   Enrollment / Admission Records Transfer Dual Enrollment Financial Assistance

Tuition Amount (if applicable):    Financial Aid Requested:

Medical & Emergency Information

Emergency Contact Phone:    Primary Care Physician:

Records Release Authorization

I hereby authorize the release and transfer of all educational records for the above-named student from the current school to the receiving school identified herein. Records to be released include, but are not limited to: academic transcripts, attendance records, immunization and health records, standardized test results, special education records (including Individualized Education Programs and evaluations), disciplinary records, and psychological or counseling reports where applicable. This authorization extends to records created prior to the date of signature and created during the pendency of this request.

The releasing entity and the receiving entity may exchange records and information as necessary to evaluate eligibility for admission, placement, or services. The parent/guardian or adult student expressly acknowledges that the schools may rely on photocopies or electronic transmissions of records and that such copies shall be treated as originals for administrative purposes.

This authorization will remain in effect for a period of 180 days from the date of signature unless earlier revoked in writing by the undersigned, provided that revocation will not affect any records released prior to receipt of written revocation.

Privacy, Use of Information, and Acknowledgments

The undersigned acknowledges that schools are required to protect student privacy and will use and disclose information only as permitted by applicable law. The undersigned consents to the use of directory information by the receiving school for purposes directly related to education and school programs unless the undersigned provides written notice to the contrary to the receiving school prior to the effective start date.

By signing below, the undersigned certifies that all information on this form is true and correct to the best of their knowledge, acknowledges responsibility for any tuition or fees as stated by the receiving school (if applicable), and agrees to comply with receiving school policies, including attendance, code of conduct, and academic requirements.

Representations, Indemnity, and Governing Provisions

The undersigned represents and warrants that they have the legal authority to execute this document on behalf of the student. The undersigned agrees to indemnify and hold harmless both the releasing and receiving educational institutions for disclosures made in accordance with this authorization, except where such institutions have acted with gross negligence or willful misconduct.

Any dispute arising out of this document or its interpretation shall be governed by the laws of the jurisdiction in which the receiving school is located. If any provision of this document is held invalid, the remaining provisions shall remain in full force and effect.

Academic Policies Acknowledgment

I acknowledge receipt and acceptance of the receiving school's essential policies where applicable, including attendance requirements, grading and promotion policies, behavioral expectations, and procedures for special education evaluation and placement. I understand that failure to comply with applicable policies may affect enrollment status or eligibility for programs.

Acknowledgment (initial each applicable item):    Attendance Policy Code of Conduct Grading & Promotion Special Education Procedures

Additional Authorizations

I consent to the use of the student's photograph or likeness for school publications, publicity, or educational purposes consistent with school policy.

I authorize the receiving school to obtain background information where required for participation in certain programs or activities.

Signatures and Certification

By signing below I certify that I am the custodial parent / legal guardian of the student listed above, or the student if 18 years of age or older, and that I have authority to execute this authorization. I understand that falsification of information may result in denial of admission or enrollment and may subject the signatory to penalties under applicable law.

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