Anchorage School District Consent for Release of Education Records

Anchorage School District Consent for Release of Education Records

AUTHORIZATION FOR USE AND/OR DISCLOSURE OF EDUCATION RECORDS
The Family Educational Rights and Privacy Act (FERPA) is a federal law that protects the privacy of student education records created or maintained by a school that receives federal funds. Completion of this document authorizes the disclosure and use of education records as described below. Completion also authorizes ASD to discuss this information with representatives of CITC to receive said information.
First Name*
Last Name*
Email
example@example.com
Student Information
Use and Disclosure Information
I, the undersigned, do hereby authorize Anchorage School District to disclose and deliver the complete educational records maintained under the above student's name including but not limited to the following:
- Grades and Transcripts
- Psychological & Educational testing
- Verbal Information
- School health records
- Special education records
- Discipline
Please list any records you do not wish to be disclosed
The education records described above shall be delivered to:

Name: Employment and Training Services Department

Organization: Cook Inlet Tribal Council

Address: 3600 San Jeronimo Dr.

Anchorage, AK 99508

Telephone Number: 907-793-3300
Purpose
This information is to be disclosed and used for the purpose of*

Special Education Evaluation & Planning§ 504 Evaluation & PlanningProvision of Special Education ServicesInformation for School NursingOther
Authorization for Redisclosure
Under federal law, the requestor (School District) may not redisclose the information identified above to any other party without your prior consent. If you wish to authorize the School District to redisclose the information identified above please mark the box below:

I authorize the School District to redisclose the education information described above and I understand that if the information is redisclosed it may not be protected by federal privileges, privacy laws or regulations
Approval
My authorization for the use, disclosure and/or redisclosure of the information identified above is voluntary. I understand that the information to be disclosed or redisclosed may include individually identifiable health information. I understand that, upon my request, I am entitled to a signed copy of this authorization form and the records to be disclosed. Unless sooner terminated in writing, this release shall remain effective for 1 year from the date signed below. A copy of this release shall be as sufficient to authorize release of information identified above as the original signed by me.
Signature of Student's Parent or Student's Legal Guardian*

Clear
Printed Name of Student's Parent or Student's Legal Guardian*
Date of Signature*

MonthDayYear
Relationship to Student*
Should be Empty:

Anchorage School District Consent for Release of Education Records

Student Information

Use and Disclosure Information

Purpose

Authorization for Redisclosure

Approval