UB Shell Lake 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

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.

Student's Email Address:   

Leave this empty:

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Signature Certificate
Document name: UB Shell Lake Information Disclosure Student
lock iconUnique Document ID: be6c44f5475e5194951ec513ffdd52e8574512fb
Timestamp Audit
September 10, 2020 10:21 am CSTUB Shell Lake Information Disclosure Student Uploaded by Lynn Warning - lwarning@fsc-corp.rg IP 75.135.161.21
September 10, 2020 10:22 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 10, 2020 10:22 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 11, 2020 1:21 pm CSTLynn Warning - lwarning@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 162.218.0.149
September 11, 2020 1:21 pm CSTKristine Fisher - kfisher@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 162.218.0.149
November 5, 2020 4:26 pm CST Document owner bcovey@fsc-corp.org has handed over this document to lwarning@fsc-corp.rg 2020-11-05 16:26:33 - 162.218.0.149
November 5, 2020 4:26 pm CSTLynn Warning - lwarning@fsc-corp.org added by Lynn Warning - lwarning@fsc-corp.rg as a CC'd Recipient Ip: 162.218.0.149
November 5, 2020 4:26 pm CSTKristine Fisher - kfisher@fsc-corp.org added by Lynn Warning - lwarning@fsc-corp.rg as a CC'd Recipient Ip: 162.218.0.149
January 27, 2021 12:40 pm CSTLynn Warning - lwarning@fsc-corp.org added by Lynn Warning - lwarning@fsc-corp.rg as a CC'd Recipient Ip: 75.135.161.21
January 27, 2021 12:40 pm CSTKristine Fisher - kfisher@fsc-corp.org added by Lynn Warning - lwarning@fsc-corp.rg as a CC'd Recipient Ip: 75.135.161.21