Code: JRA-E(1) REQUEST FOR DISCLOSURE OF STUDENT EDUCATIONAL RECORDS (Completed form to be retained, on file with student records, by appropriate school district administrator cooperating in this disclosure request).
______________________________ Name of Organization or Agency Making Disclosure Request
______________________________ Signature of Representative or Person Making Disclosure Request
______________________________ Date of Report
______________________________ Student Name
______________________________ Description of Student Records for Which Disclosure Request is Made
Statement of Relationship or Description of Legitimate Educational Interest of Person Making Disclosure Request: ____________________________________________________________________ ________________________________________________________________________________________________________________________________________
AUTHORIZATION FOR DISCLOSURE Permission is hereby granted to (school official) ______________________________ to disclose the educational records of (student name)_________________________. I understand that the educational records will be examined by ____________________________________________, and certify that I am fully authorized to grant permission for this disclosure. My relationship with the named student is: ___________________________________________________________. ___________________________________________________________ (Signature of Person Authorizing Disclosure) (Date)
RECORD/REPORT OF DISCLOSURE OF STUDENT EDUCATIONAL RECORDS
____________________________________ Date of Disclosure
Statement of Examiner: "I certify that I have, on this date, examined the educational records of (student name)_______________________________________, and that I have been advised that the disclosure of the information to a third party, without prior consent, is prohibited." _____________________________________________ __________ (Signature of Examiner) (Date)
Adoption Date: 5/15/14 Amended: 3/21/17
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