Educational ERAs Form

Educational ERAs Form

Purpose: This Authorization permits the release and electronic transmission of the student education records specified below to the designated recipient(s) and authorizes Electronic Records Access (ERAs) where indicated. This authorization is voluntary and may be revoked as provided below. The school is not required to condition enrollment, attendance, or eligibility for benefits on signing this form except where permitted by law.

Student Information

Date of Birth:    Student ID:

Parent / Guardian (if applicable)

Student is a minor and this authorization is being signed by a parent or guardian: (check if applicable)

Recipient / Authorized Party

Recipient Phone:    Recipient Email:

Records To Be Released (select all that apply)

Official and unofficial transcripts
Grades or academic progress reports
Attendance records and tardies
Disciplinary records and incident reports
Health and immunization records
Special education records, IEPs, evaluations
Standardized test scores and assessment reports
Financial aid and billing records as related to enrollment
Enrollment verification and dates of attendance

Purpose of Disclosure

Application for further education or transfer
Transfer to another educational institution
Legal proceedings or representation
Scholarship or financial assistance application
Employment verification or background review
Personal use by the student or parent/guardian
Other (describe below)

Delivery & Electronic Access

Delivery method authorized (select all that apply):
Mail to recipient address
Email to recipient email (I acknowledge email may not be secure)
Fax to recipient fax number
In-person pickup by recipient with valid ID
Electronic portal or secure download (ERAs)

Effective Date:    Expiration Date:

One-time release:    Valid until revoked in writing:

Authorization, Redisclosure, and Revocation

I hereby authorize the release of the education records described above to the recipient named herein. This authorization includes permission for the school to transmit records electronically where indicated and to grant Electronic Records Access (ERAs) to the recipient for the scope and duration set forth. I understand that once records are disclosed to the recipient, those records may be subject to redisclosure by the recipient and may no longer be protected by this institution's policies.

I understand that this authorization may be revoked at any time by delivering a written revocation to the school registrar; however, revocation will not affect disclosures already made pursuant to this authorization prior to receipt of the revocation. The school may require verification of identity prior to processing a revocation request.

Acknowledgment of Rights and Certification

By signing below I certify that I am the student named above or the student's parent or legal guardian and that I have the authority to authorize the release of these records. I understand that I have the right to inspect and obtain a copy of the records disclosed under this authorization unless restricted by law. I understand that signing this form is voluntary and that I may revoke authorization as set forth above.

I further certify that the information provided on this form is true and correct to the best of my knowledge.

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