UB Central Information Disclosure - Student


Student's Name:  

Date of Birth:

WHAT:

I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange) of all education records and other information directly or indirectly related to my/my child's education and career development. This includes specific permission to release:

  • Progress records, including office student academic/administrative records (identifying information, grade level completed, grades, class rank, attendance records, and group aptitude and achievement test results)
  • Medical and/or related health records
  • Psychological evaluations or social work reports
  • Law enforcement records
  • Multidisciplinary team evaluations and related reports
  • Individual education programs
  • Participation in free/reduced lunch program
  • Behavioral records
  • National Student Clearinghouse data for enrollment verification and tracking purposes

TO WHOM: Forward Service Corporation employees assigned to the Upward Bound program.

PURPOSE: To determine Upward Bound program eligibility, to develop and implement an Upward Bound program plan, and to evaluate progress in the program for the student named above.

Student's Email Address:  

Leave this empty:

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Forward Service Corporation https://fsc-corp.org
Signature Certificate
Document name: UB Central Information Disclosure - Student
lock iconUnique Document ID: fa23f93e64a61b0b886a45372d6c7fd8b4428a3f
Timestamp Audit
September 9, 2020 11:02 am CDTUB Central Information Disclosure - Student Uploaded by Brian Covey - bcovey@fsc-corp.org IP 162.218.0.149
September 9, 2020 11:10 am CDTCiara Wade - cwade@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81
September 9, 2020 11:10 am CDTShawn Perkins - sperkins@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81
September 9, 2020 2:14 pm CDTCiara Wade - cwade@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81
September 9, 2020 2:14 pm CDTShawn Perkins - sperkins@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81
September 9, 2020 2:29 pm CDTCiara Wade - cwade@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81
September 9, 2020 2:29 pm CDTShawn Perkins - sperkins@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81
September 11, 2020 1:30 pm CDTCiara Wade - cwade@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 162.218.0.149
September 11, 2020 1:30 pm CDTShawn Perkins - sperkins@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 162.218.0.149

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