A Member of The Texas A&M University System
College of
This release represents your written consent to permit the university to disclose educational
records and any information contained therein to the specific individual(s) identified below.
Please read this document carefully and fill in all blanks.
I, [print full name] AM / WA S [circle one]
a student at Texas A&M International University (TAMIU) in the College of Education and
hereby give my voluntary consent to university officials:
A. To disclose the following records:
Records relating to any of my field-based experiences
Records relating to my performance in the field
Records relating to certification exams
B. To the following person(s):
School districts or other agencies association with field-based experiences
School-based/Agency-based administrators
School-based/Agency-based mentors
TAMIU faculty
C. These records are being released for the purpose of:
Conversing and reviewing performance
Acquiring feedback
Procuring required signatures
I understand that under the Family Educational Rights and Privacy Act of 1974 (“FERPA”
20 USC 1232g; 34 CFR §99; commonly known as the “Buckley Amendment”) no disclosure
of my records can be made without my written consent unless otherwise provided for in
legal statutes and judicial decisions. I also understand that I may revoke this consent at
any time (via written request to the College of Education) except to the extent that action has
already been taken upon this release. Further, without such a release, I am unable to
participate in any clinical or field-based experiences.
Signature of Student/Former Student Date
Student Id. No.:
Date of Birth:
Student’s Telephone No.:
TAMUS-OGC-JMB-01/11/2012 COE Rev.8/16/13 (sa)
5201 University Boulevard, Laredo, Texas 78041-1900, U.S.A. (956) 326-2420 FAX (956) 326-2419
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