UB JAM Information Disclosure Parent


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.

Name of Parent/Legal Guardian/Other Responsible Adult: \

Email Address:  
 

Leave this empty:

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Forward Service Corporation https://fsc-corp.org
Signature Certificate
Document name: UB JAM Information Disclosure Parent
lock iconUnique Document ID: 681489e3624f1f68601efa1b7c5049f37f9e91cd
Timestamp Audit
September 10, 2020 9:23 am CSTUB JAM Information Disclosure Parent Uploaded by Brian Covey - bcovey@fsc-corp.org IP 162.218.0.149
September 10, 2020 9:24 am CSTKristine Fisher - kfisher@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81
September 10, 2020 9:24 am CSTLynn Warning - lwarning@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81
September 26, 2020 3:09 pm CSTUB JAM - ubjam@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81
November 3, 2020 4:21 pm CST Document owner bcovey@fsc-corp.org has handed over this document to lwarning@fsc-corp.rg 2020-11-03 16:21:07 - 162.218.0.149
November 3, 2020 4:21 pm CSTUB JAM - ubjam@fsc-corp.org added by Lynn Warning - lwarning@fsc-corp.rg as a CC'd Recipient Ip: 162.218.0.149