Student Consent to Release

STUDENT CONSENT TO RELEASE

Student Information

Student Name:

Date of Birth:    Student ID:    Grade / Program:

Parent / Guardian (if applicable)

Recipient of Records

Phone:    Email:    Fax:

Records to Be Released (check all that apply)

Academic transcript, grades, schedule
Disciplinary records and incident reports
Counseling / psychological records
Immunization and health records
Financial and billing records
Special education / IEP / 504 records
Other (describe below)

Purpose and Manner of Disclosure

Method of Disclosure: Email Mail Fax Electronic transfer In-person pickup

Sensitive Information

I specifically authorize the release of the following sensitive records (select to authorize). If not selected, such records will not be disclosed:

Substance abuse treatment records (if any)
Mental health / psychotherapy notes
HIV/AIDS-related information
Genetic testing results

Duration and Revocation

This authorization is effective immediately upon my signature and will expire on unless earlier revoked in writing. Revocation must be delivered in writing to the school records office and will not affect disclosures already made in reliance on this consent.

Authorization and Legal Acknowledgment

By signing below I authorize the educational institution named below to disclose the records and information described in this form to the recipient named above for the purpose(s) described. I understand that the information released pursuant to this authorization may include confidential education, health, counseling, disciplinary and financial records as indicated. I release the educational institution and its agents from any liability arising from the disclosure of information pursuant to this authorization except as prohibited by law.

I understand that I may refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment, enrollment, or eligibility for benefits unless the information is necessary to determine such eligibility. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy laws.

Certification

I certify that I am the student named above, or I am the parent or legal guardian of the student and have the authority to execute this release on behalf of the student. I confirm that the information provided on this form is true and correct to the best of my knowledge.

School / Issuing Office (for internal use)

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