Student Information Waiver Form

Student Information Waiver Form

Student Information

Date of Birth:    Student ID:    Grade / Program:

Primary Phone:    Email:

Parent / Guardian (if applicable)

Relation to Student:    Phone:

Authorization and Release

I, the undersigned, authorize the educational institution named above to collect, use, and disclose the student information specified below for the purposes checked. I understand that this authorization permits disclosures to school officials, contracted service providers, partnering organizations, and other third parties as required for the stated purposes. I acknowledge that this authorization is voluntary and that I may revoke it in writing as described below.

Directory information (name, grade, school, photograph)
Academic records and transcripts
Attendance and enrollment verification
Disciplinary records (limited to non-confidential disciplinary summaries)
Health or emergency medical information (limited to information necessary for emergency response)
Photographs, video, and audio recordings for publication or promotional use
Information shared with approved third-party service providers for educational services

School publications, yearbook, and promotional materials
School-managed social media and communications
Enrollment or achievement verification for third parties (employers, scholarship committees)
Educational research and program evaluation (data may be anonymized)
Emergency response and safety communications

Limitations and Important Notices

This authorization does not permit release of psychotherapy notes, information protected under different statutory regimes without separate consent, or other records the institution is legally prohibited from disclosing. The institution will take reasonable steps to protect the confidentiality of disclosed information, but cannot control the handling of information once released to external third parties. The undersigned releases the institution from liability for disclosures made in accordance with this authorization.

Duration and Revocation

This authorization is effective beginning on: and will expire on: unless earlier revoked in writing. To revoke this authorization, deliver a signed written notice to the school office. Revocation will not apply to disclosures already made in reliance on this authorization prior to receipt of the revocation.

Emergency / Medical Considerations (Optional)

Relationship:    Phone:

Acknowledgment and Certification

By signing below I certify that I am the student named above or the student's parent or legal guardian with authority to execute this authorization. I have read and understand the terms of this waiver, and I authorize disclosure of the student information as indicated. I understand that signing this form is voluntary and that I may request copies of records disclosed pursuant to this authorization.

Signatory represents that the signatory is: Student    Parent / Legal Guardian

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