Student PTRE Document

Student PTRE Document — Permission to Transfer or Release Education Records

This Permission to Transfer or Release Education Records (PTRE) authorizes the release of the education records identified below. Student Name: Date of Birth: Student ID:

Grade or Program: Current School:

Recipient of Records

Records to Be Released (Select all that apply)

Official or unofficial transcript(s)
Report cards/grades
Attendance records
Immunization/health records
Evaluations, assessments, standardized test scores
Special education records and IEP/504 plans
Disciplinary records
Financial/account records related to tuition or fees
Other (describe):

Purpose and Limits of Disclosure

Enrollment/transfer
Educational evaluation or placement
Scholarship or financial assistance
Legal/administrative proceedings
Personal use by student/parent
Other (explain):

From: To:

Authorization, Duration, and Revocation

I hereby authorize the release of the education records specified above to the recipient named in this form. I understand that:

1. This authorization is voluntary and may be revoked in writing at any time, except to the extent that action has already been taken in reliance on it. To revoke, deliver written notice to the records custodian at the current school. Revocation does not affect disclosures made prior to receipt of the revocation.

2. Unless an earlier date or event is specified below, this authorization expires on: . If no expiration date is provided, the authorization will expire one year from the signature date.

3. I understand that the records disclosed pursuant to this authorization may include information protected by privacy laws, including educational, medical, and disciplinary records, and that the recipient may re-disclose those records only as permitted by law.

Delivery Method & Fees

Delivery method (select preferred): Mail In-person pick-up Secure electronic delivery Fax

Emergency & Additional Instructions

Acknowledgment of Identity and Authority

By signing below, I certify that I am the student named above or that I am the parent/guardian or legal representative authorized to obtain the records for the student. I further certify that the information I have provided is true and accurate and that I understand the limitations and rights described in this form.

Certification: The undersigned acknowledges that unauthorized disclosure of certain education or health information may be restricted by law. This authorization is given voluntarily and constitutes a release of information only to the extent expressly authorized herein. The recipient is authorized to use and, if permitted by law, re-disclose the information only for the purpose stated above.

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