Educational Records Authority Form

EDUCATIONAL RECORDS AUTHORITY FORM

Student Information

Student Name:

Date of Birth:    Student ID:

Parent / Legal Guardian (if applicable)

Records To Be Released

Select specific records authorized for disclosure (initial each applicable category and sign below to authorize release of sensitive records as required):

Official academic transcript (all terms)

Grades, progress reports, course schedules

Attendance records and enrollment history

Disciplinary records and incident reports

Special education records and Individualized Education Program (IEP)

Health/medical records (including immunizations)

Counseling, psychological, or social work records

Other (describe)

Purpose of Disclosure

Purpose for which records are to be used (check all that apply):

Transfer to another educational institution

College/university application

Employment or internship verification

Personal use by the authorizing party

Recipient Information

Method of Release

Choose delivery method(s):

Mail

Fax

Secure electronic transmission (encrypted)

Duration and Revocation

This authorization expires on:    Or upon completion of the purpose indicated:

I understand that I may revoke this authorization at any time by submitting a signed, written revocation to the school’s records office. Revocation is effective upon receipt by the records office and will not apply to disclosures already made in reliance on this authorization.

Acknowledgement of revocation rights:

Special Authorizations for Sensitive Records

Certain records require explicit authorization for release. Indicate any sensitive categories you specifically authorize:

HIV/AIDS test results or status

Substance use disorder treatment records

Psychotherapy notes

I understand that if I wish to authorize release of records protected by special statutes, I must check the applicable boxes above. Checking these boxes is my explicit consent to disclose those records.

Fees and Conditions

I acknowledge that reasonable copying or mailing fees may apply and may be charged to the recipient or to me prior to release, in accordance with institutional policy.

Acknowledgement of potential fees:

Certification and Authorization

By signing below I certify that I am the student named herein or the parent/legal guardian authorized to act on the student's behalf. I authorize the release of the records described above to the named recipient for the purposes stated. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the institution. I release the institution and its agents from any liability that may arise from the disclosure of the records as authorized in this document.

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