Notice: Trying to get property 'first_name' of non-object in /var/www/wp-content/plugins/e-signature/lib/Shortcode.php on line 829

Notice: Trying to get property 'last_name' of non-object in /var/www/wp-content/plugins/e-signature/lib/Shortcode.php on line 830

Notice: Trying to get property 'user_email' of non-object in /var/www/wp-content/plugins/e-signature/lib/Shortcode.php on line 831

Notice: Trying to get property 'user_id' of non-object in /var/www/wp-content/plugins/e-signature-business-add-ons/esig-auto-add-my-signature/admin/esig-aams-admin.php on line 315

Notice: Trying to get property 'user_id' of non-object in /var/www/wp-content/plugins/e-signature-business-add-ons/esig-auto-add-my-signature/admin/esig-aams-admin.php on line 353

UB Madison 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

Upward Bound Program:  

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:

Signature arrow

Signature Certificate
Document name: UB Madison Information Disclosure Parent
lock iconUnique Document ID: 0b31d3f720e6344262e63f21d369b74ea431ac5f
Timestamp Audit
September 9, 2020 2:39 pm CSTUB Madison Information Disclosure Parent Uploaded by Shawn Perkins - sperkins@fsc-corp.org IP 75.135.161.21
September 9, 2020 2:42 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 2:42 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 26, 2020 3:01 pm CSTUB Madison - ub_madison@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81
October 27, 2020 12:31 pm CSTUB Madison - ub_madison@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81
October 30, 2020 9:11 am CST Document owner bcovey@fsc-corp.org has handed over this document to sperkins@fsc-corp.org 2020-10-30 09:11:22 - 69.130.248.81
October 30, 2020 9:11 am CSTUB Madison - ub_madison@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 Madison - ub_madison@fsc-corp.org added by Shawn Perkins - sperkins@fsc-corp.org as a CC'd Recipient Ip: 75.135.161.21