Seattle Public Schools: Authorization for Exchange of Information and Records

"*" indicates required fields

PURPOSE:

As a parent or guardian (adult student) you have the right to give permission or not give permission for the release of your child’s (your) records with other persons or agencies. This request provides you with the opportunity to approve or not approve such a request unless release of records is allowed under one of the exceptions under the rules implementing the federal Education Rights and Privacy Act (for example, transfer of records from one school district to another). It also provides you the opportunity to talk with the school district and ask for an explanation as to why the information is being requested and by whom.

Student Name*

First Last

Student ID#*

Date of Birth*

School District: Seattle Public Schools

I hereby authorize the release of information & records

From:*

(Name of agency/person)

To:*

(Name of agency/person)

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

The reason for disclosing the record(s) is:*

Parent/guardian/adult student signature*

By checking the field below, you agree to release this student's record(s)

I understand that the information obtained will be treated in a confidential manner and will not be transmitted to a third party without my permission.

Name*

First Last

Date*

Phone

This field is for validation purposes and should be left unchanged.

Seattle Public Schools: Authorization for Exchange of Information and Records

PURPOSE:

I hereby authorize the release of information & records

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