Student Record Release

STUDENT RECORD RELEASE

This Student Record Release authorizes the disclosure of education and related records as designated below. Release of records is permitted only to the named recipient for the stated purpose and duration. The authorizing party certifies that they are the student or the parent/guardian or legal representative with authority to execute this release.

Student Information

Date of Birth:    Student ID:    Grade / Program:

Phone:    Email:

Parent / Guardian (Complete if student is under 18)

Relationship:    Phone:    Email:

Records to Be Released

Please select specific categories of records to be disclosed. Check only those categories you authorize for release.

Transcript(s) (All academic transcripts and grade reports)

Disciplinary records and incident reports

Attendance and enrollment records

Health and immunization records (excluding psychotherapy notes)

Special education / IEP / 504 records

Standardized test scores and assessment reports

Other:

Note: Psychotherapy notes and certain other sensitive records may require a separate, specific authorization. This release does not authorize release of psychotherapy notes unless explicitly stated in the instructions above.

Recipient / Third Party

Phone:    Email / Fax:

Preferred Method of Delivery:    Mail    Fax    Secure Electronic Transfer    In-person pickup

Purpose and Duration

Purpose of Disclosure:    Enrollment / Transfer    Employment    Medical / Health Care    Legal / Court    Other

Records requested for the period: From to .

This authorization will expire on unless earlier revoked in writing. If no expiration date is provided, this authorization expires one year from the date of signature.

Consent, Limitations, and Acknowledgments

By signing below, I authorize the named institution to disclose the records specified above to the named recipient. I understand and acknowledge the following terms:

1. Scope: This authorization applies only to the categories of records identified above and does not permit release of records beyond those categories unless explicitly stated.
2. Revocation: I may revoke this authorization at any time by delivering a written revocation to the records custodian, except to the extent that action has already been taken in reliance on this authorization.
3. Re-disclosure: I understand that the recipient may re-disclose information contained in the released records, and re-disclosure may no longer be protected by federal or state privacy laws.
4. Fees: I may be charged a reasonable fee to reproduce or transmit records in accordance with institutional policies.
5. Voluntary: Signing this authorization is voluntary and refusal to sign will not affect eligibility for benefits, except where release of records is necessary to receive services or enrollment as requested.
6. Certification: I certify that I am the student, parent/guardian, or legal representative with authority to sign and that the information provided is true and correct.

I understand that a photocopy or electronic copy of this authorization is valid and carries the same force as the original.

Authorizer Information

Relationship of authorizer to student:    Student (18 or older)    Parent / Guardian    Legal Representative

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