Fillable CONSENT TO RELEASE STUDENT EDUCATION RECORDS TO A (Poudre School District)

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CONSENT TO RELEASE STUDENT EDUCATION RECORDS TO A (Poudre School District)

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  • 14 check-boxes
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CONSENT TO RELEASE STUDENT EDUCATION RECORDS TO A
TH
IRD PARTY
9/24/2018
Student’s Information
Name at Time of PSD School Attendance:
Last Name First Name MI
/ /
Date of Birth Last PSD School Attended Year
Cu
rrent Name (if different from above):
Last Name First Name MI
Current Phone Number Current Email
Records Requested
Attendance Records
(Specify Dates: ______________)
Discipline Records
Standardized Test Scores
Immunization Records
Report Card/ Transcript
Student Profile
Enrollment History
IEP/504/Spec. Ed. Records
(Specify: ___________________)
All the Above (Student
Cumulative File)
Safety Plan
Other Records (Please be specific):
*Purpose of release must be for ALL items selected above and will be released to ALL Third Parties Listed on page
2 of this Consent*
Purpose for the Disclosure of the Requested Records – Be Specific
Please describe the purpose for the requested disclosing of the records:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
*PSD will release ALL the specified records requested with ALL Third Parties Listed on page 2 of this Consent*
Communication Types and Duration
Poudre School District may release documents and other records contained in the specified educational record.
Poudre School District may discuss/verbally release information contained in the specified education record.
Poudre School District may discuss via email information contained in the specified education record.
Duration of Release – (Check One)
One-Time Release Current Academic Yea
r O
ther expiration date: _________________
This release expires on the date indicated above unless revoked in writing. Notwithstanding the above, this Consent
expires on July 31
st
of the current year.
Page 1 of 2
CONSENT TO RELEASE STUDENT EDUCATION RECORDS TO A
TH
IRD PARTY
9/24/2018
Third Party (Person, Company or Agency) to Whom the Records are to be Released.
Contact Name Company/Agency
______________________________________________ ________________________________________________
Phone Number Email
Contact Name Company/Agency
______________________________________________ ________________________________________________
Phone Number Email
Contact Name Company/Agency
______________________________________________ ________________________________________________
Phone Number Email
Authorization to Release Records
By signing below, I authorize the appropriate office/official at Poudre School District R-1 to release my specified
educational record(s) to the Third-Party or Parties listed above subject to the terms specified in this document.
I am the student named above and am 18 years of age or attending a post-secondary educational institution.
Signature: Date:
I
am the parent/guardian of above named student.
Print Name:
Signature: Date:
Re
ferences: FERPA (20 U.S.C. § 1232g; 34 CFR 99.31) & Poudre School District Policy JRA/JRC – Student Records/Release of Information on Students.
THIS ORIGINAL FORM MUST BE PUT IN THE STUDENTS CUMULATIVE ACADEMIC FILE OR SENT TO
THE POUDRE SCHOOL DISTRICT RECORDS DEPARTMENT – MARKED FOR DISCLOSURE
Page 2 of 2
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CONSENT TO RELEASE STUDENT EDUCATION RECORDS TO A (Poudre School District)

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Completed 14 June 2021

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