_______________________________________________ ____________
_______________________________ ____________ ____________
Name of Student Date of Birth Student ID
(if known)
Family Educational Rights and Privacy Act (FERPA) Information Disclosure Consent
The Family Educational Rights and Privacy Act (FERPA) is a federal law that protects the privacy of student education records
and requires the consent of the parent/guardian prior to the disclosure of personally identifiable student records unless the
disclosure is specifically authorized by one or more provisions of FERPA. If the student is aged 18 or older or is attending a post-
secondary school, the student should complete this consent form instead of the parent/guardian. Please visit
https://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html for additional information regarding the exceptions under FERPA
which authorize school divisions to release student records and information to certain parties under specified conditions without
prior written consent.
PWCS organizes the student educational record into the categories set forth in the following list. If you wish PWCS to provide
access to the student’s entire student educational record to the person or organization you identify below, please select “All of the
Above.” If you wish to provide access to only certain portions of the student’s student educational record, please select any of the
specific categories listed above that choice and the disclosure will be limited only to records in the category or categories selected.
If you wish to specify a record or records that is not listed in the categories provided, please select the “Other” option and clearly
identify the record or records you wish to be disclosed.
Cumulative
Special Education/Intervention Test Scores
Gifted Education
English Language Learner
Behavior/Discipline
Clinic/Health
Social/Emotional
Attendance Records only
Transcript only
Other: (please specify)
_____________________________
All of the above
Please list any persons or organizations to whom you grant permission for PWCS to disclose the records you have selected above.
If you wish to authorize additional disclosures, you may submit additional forms.
Name Phone Email Purpose
Example: Jane Smith, Counselor 999-999-9999 janesmith@email.com counseling services
___________________________ _____________ ____________________________ __________________
___________________________ _____________ ____________________________ __________________
___________________________ _____________ ____________________________ __________________
By signing this document (physically or digitally), I am confirming: (1) that I am authorized to provide consent to disclosure the
student’s records because I am the student’s parent or legal guardian or because I am the student and I am aged 18 or older or I am
attending a postsecondary school; (2) that I am giving my consent for PWCS to disclose the student records I have identified
above to the persons or organizations I have identified above. I understand that by granting this consent, I am also authorizing
PWCS to discuss the contents of these records with the persons or organizations I have identified; (3) that this consent will
continue unless or until I notify the PWCS FERPA Officer (FERPAOfficer@pwcs.edu) in writing that I revoke my consent. I also
understand that I may revoke my consent at any time; and (4) I acknowledge the retention/disposition notice highlighted below.
Parent/Guardian/ Eligible Student
Signature (required)
Date
Student educational records are forwarded to the PWCS Records Center after withdrawal or graduation for a retention period
of five (5) years. After five (5) years the records are purged and only long-term documents are maintained, per the requirements
of the Library of Virginia General Schedules and/or PWCS Policies/Regulations. You may request the original student
educational record prior to June 1 of the disposition year by contacting the PWCS Records Center (703) 791-7395.
