Coeur d’Alene Tribe
Department of Education
1115 B Street
P.O. Box 408
Plummer, Idaho 83851
208.686.1800 Fax 208.686.5804
Parent Authorization for Student Participation and Consent for Release of Information
Student Name: ___________________________________ Grade: ______
Tribal Affiliation (If applicable): ______________________ Enrollment Number: ________________________________
Phone Number #1: ________________________________ Phone Number #2: _________________________________
Mailing Address: __________________________________ Email: ___________________________
The Coeur d’Alene Tribe’s Department of Education would like to offer your child the opportunity to participate in these programs while
they attend school in the Plummer-Worley School District:
1. Johnson O’Malley (JOM) program ensures that students in grades 7-8 are prepared for the transition to high school, and in grades
9-12, students are prepared to pursue high school graduation.
2. Imagine The Future Program (ITF) supports students in grades 9-12 who will enter and post-secondary institutions and/or the
3. Native American Career and Technical Education Program (NACTEP) provides training and funding for pre-college academics and
career planning for students in grades 9-12 for two-year post-secondary professional technical programs, two-year academic
degrees, and preparation for life after high school.
Participants have the opportunity to receive academic/career counseling, one-on-one academic assistance, and participate in college and
career readiness events throughout the year.
In order to establish a mutual exchange of educational information regarding your child, the Coeur d’Alene Tribe’s Department of
Education requests permission to access and/or provide services as listed below:
Official and unofficial transcripts
Local and state assessment scores
Attendance records
Grade reports
Current class schedules
Family Link access
Field trip or Summer Internship (permission to transport)
Video and/or photos release to promote CDA Dept. of Ed.
FERPA (Privacy Act)
The Family Educational Rights and Privacy Act (FERPA) is a federal privacy law that affords parents the right to have access to their
children’s education records, seek to have the records amended, and consent to the disclosure of personally identifiable information from
education records, except as provided by law.
By completing and returning this document, I am authorizing the Coeur d’Alene Tribe’s Department of Education to access Lakeside School
reports or records of my son/daughter in order to establish a plan for academic success. I understand that this information is considered a
student education record. Further, I understand that by signing this release, I am waiving my right to keep this information confidential
under the Family Education Rights and Privacy Act (FERPA), and that the information will be used confidentially by DOE staff to support
educational success of my child. I certify that my consent for disclosure of this information is entirely voluntary. I understand this consent
for disclosure of information can be revoked by me in writing at any time, but will not affect the information released under my previous
consent. If I wish to make any changes to my consent for release, I understand I will need to complete and file a new form.
Family Link Username: ____________________________ Family Link Password: _______________________________
Parent/Guardian Signature: ________________________ Parent/Guardian Printed Name: _______________________ Date: __ /__ /__
Tribal Affiliation (If applicable): ______________________ Enrollment Number: ________________________________
If you have any questions regarding these programs, please feel free to contact Helen Muffly, JOM Manager, at (208) 686-6108 or Bryan
Samuels, ITF Coordinator, at (208) 686-0803 or Eva Windlin NACTEP Manager at (208)686-0604.
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