Student CPI Form

STUDENT CPI FORM

This Student CPI Form documents authorization for the collection, storage, use, and disclosure of the student's Confidential Personally Identifiable Information (CPI) maintained by the educational institution identified below. CPI includes education records, health and medical information, special education records, disciplinary records, assessment results, biometric data, and other records that reasonably identify the student. The information provided on this form will be handled in accordance with applicable privacy and confidentiality policies. By completing and signing this form, the signer grants the school the permissions described in this document and acknowledges the limits and duration of that consent.

Student Information

Student Name:

Date of Birth:    Student ID:

Grade/Program:    School:

Parent / Guardian Information (if student is a minor)

Types of CPI to be Collected, Maintained, or Shared

Select all categories of student CPI for which this authorization is granted:

Educational records (enrollment, grades, transcripts)

Health and medical information (immunizations, medical alerts)

Special education records and Individualized Education Program (IEP) documents

Behavioral and disciplinary records

Assessment scores and testing data

Biometric data (where collected)

Other (describe below)

Authorized Recipients and Purpose

Purpose(s) for which CPI may be used and disclosed (check all that apply and specify additional detail where required):

Instructional and academic support

Health services and medical accommodations

Safety, crisis response, and law enforcement liaison

Duration of Consent and Revocation

Effective Date:    End Date (if any):

This consent remains in effect until the end date above or until revoked in writing by the signer. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the written revocation. To revoke consent, submit a signed written notice to the school official identified below.

Protections, Student Rights, and Disclosures

The institution will implement administrative, technical, and physical safeguards designed to protect CPI from unauthorized access, disclosure, alteration, and destruction. The signer has the right to request access to records, request amendment of inaccurate information, and obtain an accounting of disclosures made pursuant to this authorization, subject to applicable law and institutional policy. The institution may disclose CPI to third-party service providers under contractual terms that require similar confidentiality protections.

I acknowledge that I have read and understand my rights as described above.

Special Instructions or Limitations

Certification

By signing below, I certify that I am authorized to provide this consent for the student identified above (either as the student if of legal age or as the parent/legal guardian). I authorize the school to collect, use, maintain, and disclose the categories of CPI checked above to the authorized recipients for the purposes described. I acknowledge that I have been provided with sufficient information to make an informed decision, that I may revoke this authorization in writing as described above, and that any revocation will not apply retroactively to disclosures made prior to receipt of revocation.

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