UB Unity 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:

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Forward Service Corporation https://fsc-corp.org
Signature Certificate
Document name: UB Unity Information Disclosure Parent
lock iconUnique Document ID: 44de10c808b16f4a1e31cc3605f5a3418342cb7b
Timestamp Audit
September 10, 2020 11:18 am CSTUB Unity Information Disclosure Parent Uploaded by Brian Covey - bcovey@fsc-corp.org IP 69.130.248.81
September 10, 2020 11:19 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 11:19 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 3:20 pm CSTUB West - ubwest@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81
October 27, 2020 12:55 pm CST Document owner bcovey@fsc-corp.org has handed over this document to lwarning@fsc-corp.rg 2020-10-27 12:55:22 - 69.130.248.81
October 27, 2020 12:55 pm CSTUB West - ubwest@fsc-corp.org added by Lynn Warning - lwarning@fsc-corp.rg as a CC'd Recipient Ip: 69.130.248.81