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UB Spooner Math Science 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

FROM WHOM: School I am/my child is enrolled in:

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:

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Timestamp

Audit

September 10, 2020 10:57 am CST

UB Spooner Math Science Information Disclosure Student Uploaded by Lynn Warning - lwarning@fsc-corp.rg IP 75.135.161.21

September 10, 2020 10:57 am CST

Kristine 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 10:57 am CST

Lynn Warning - lwarning@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81

September 11, 2020 12:41 pm CST

Kristine Fisher - kfisher@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 162.218.0.149

September 11, 2020 12:41 pm CST

Lynn Warning - lwarning@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 162.218.0.149

September 26, 2020 3:16 pm CST

UB Math Science West - ubmsw@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81

October 30, 2020 12:32 pm CST

Document owner bcovey@fsc-corp.org has handed over this document to lwarning@fsc-corp.rg 2020-10-30 12:32:07 - 69.130.248.81

October 30, 2020 12:32 pm CST

UB Math Science West - ubmsw@fsc-corp.org added by Lynn Warning - lwarning@fsc-corp.rg as a CC'd Recipient Ip: 69.130.248.81

January 27, 2021 12:34 pm CST

UB Math Science West - ubmsw@fsc-corp.org added by Lynn Warning - lwarning@fsc-corp.rg as a CC'd Recipient Ip: 75.135.161.21