Student Permission to Release

STUDENT PERMISSION TO RELEASE EDUCATIONAL RECORDS AND INFORMATION

School Name:

Student Information

Student Name:

Date of Birth:    Grade/Program:

Requesting Party / Recipient

Recipient Phone:    Recipient Email:

Records and Information To Be Released

I authorize the release of the following categories of records (check all that apply):

Academic transcripts, grades, course schedule
Special education/IEP/504 records
Attendance and enrollment records
Disciplinary records and incident reports
Health and immunization records
Financial account and billing records
Other (specify):

Purpose of Disclosure

The records are requested for the following purpose(s) (check all that apply):

Transfer to another school/program
Medical or health care coordination
Legal purposes
Educational research or program evaluation
Personal use by parent/guardian or student
Other (explain):

Method of Release

I authorize the school to release records by the following methods (check all that apply):

Paper copy by mail or in-person delivery
Electronic transmission by email
Fax transmission
Secure electronic portal

If electronic transmission is authorized, I acknowledge that electronic delivery may involve risks of interception or unintended disclosure. By authorizing electronic release I accept those risks and release the school from liability for unauthorized access unless caused by the school's gross negligence or willful misconduct.

Authorization Period

This authorization is effective from through , unless earlier revoked in writing.

Check here for a single, one-time disclosure only:

Conditions, Rights, and Acknowledgements

The undersigned certifies that they are the student (if age 18 or older), or the parent/legal guardian of the student with authority to execute this authorization. The undersigned authorizes the school named above to disclose and transfer the records specified to the recipient named herein. This release includes the right to obtain copies and to transmit records in the manner indicated.

I understand that information disclosed under this authorization may include records protected by federal and state privacy laws. Unless otherwise limited above, this authorization permits disclosure of the categories checked, including sensitive information that may be necessary for the stated purpose.

I understand that I may revoke this authorization at any time by delivering a written revocation to the school's records office, except to the extent that the school has already acted in reliance on this authorization. Revocation will not affect disclosures made prior to receipt of the revocation.

I understand that the recipient may re-disclose information received and that the school is not responsible for subsequent disclosures by the recipient. The school may impose a reasonable fee for copying or transmitting records in accordance with institutional policy.

Additional Instructions / Limitations

Certification: I certify that the information provided in this form is true and accurate to the best of my knowledge. I give my informed consent to the disclosure described above and acknowledge that I have read and understand the terms of this authorization.

Sign Now