FERPA Consent to Release Educational Records and Information
[print full name] am a candidate at Our Lady of the Lake
University and hereby give my voluntary consent to officials:
This release represents your written consent to permit Our Lady of the Lake 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, _____________________________________________________
A. To disclose the following records:
Records relating to any of my field-based and/or clinical teaching experiences/performance
Records relating to my performance in the field
TExES test score results
B. To the following person(s):
School districts or other agencies associated with field-based experiences
School-based/Agency-based administrators
School-based/Agency-based cooperating teachers/mentors
Provost (VPAA)
Associate (VPAA)
Dean: School of Professional Studies/Worden School of Social Services
Program Faculty: Chair, Education Department
Program Faculty: Director of Field Experience
Program Faculty: Advisor
Program Faculty: University Supervisor
Certification Officer
Registrars Office
Program faculty
Compliance Officer
ADA Coordinator
C. These records are being released for the purpose of:
Conversing and reviewing performance
Acquiring feedback
Procuring required signatures
Recommendation for Probationary Certificate and Renewal
Recommendation for 5-year Standard Certificate
State Accountability Reports
I understand that under the Family Educational Rights and Privacy Act of 1974 (“FERPA” 20 USC 123g; 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 educator preparation
program) 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 field-based experiences including 30 clock hours of
Signature of Candidate Date
Candidate TEA ID Number:
____
observation, clinical teaching, student teaching, or internship.
______________________________________________ ____________________
________________________________________
Date of Birth: ________________________________________________________
Student Email Address: ____________________________________________
Phone Number: ___________________________________________________
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