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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:

Signature arrow

Signature Certificate
Document name: UB Central Information Disclosure - Student
lock iconUnique Document ID: ca14eb1c1d01d0baf62e0b7b6600c7de745bb0d7
Timestamp Audit
September 9, 2020 11:02 am CSTUB Central Information Disclosure - Student Uploaded by Shawn Perkins - sperkins@fsc-corp.org IP 75.135.161.21
September 9, 2020 11:10 am CSTCiara 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 CSTShawn 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 CSTCiara 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 CSTShawn 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 CSTCiara 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 CSTShawn 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 CSTCiara 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 CSTShawn Perkins - sperkins@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 162.218.0.149
September 26, 2020 3:01 pm CSTUB Central - ubcentral@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81
November 2, 2020 7:25 am CST Document owner bcovey@fsc-corp.org has handed over this document to sperkins@fsc-corp.org 2020-11-02 07:25:56 - 69.130.248.81
November 2, 2020 7:25 am CSTUB Central - ubcentral@fsc-corp.org added by Shawn Perkins - sperkins@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81
January 27, 2021 12:43 pm CSTUB Central - ubcentral@fsc-corp.org added by Shawn Perkins - sperkins@fsc-corp.org as a CC'd Recipient Ip: 75.135.161.21