UB Central 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

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

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 of Parent/Legal Guardian/Other Responsible Adult:  

Leave this empty:

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Forward Service Corporation https://fsc-corp.org
Signature Certificate
Document name: UB Central Information Disclosure Parent
lock iconUnique Document ID: 11c6f870d1ca1b8bc1e41dfb8db7b3a21c3b4489
Timestamp Audit
July 23, 2020 10:32 am CDTUB Central Information Disclosure Parent Uploaded by Brian Covey - bcovey@fsc-corp.org IP 69.130.248.81
July 23, 2020 10:53 am CDTCiara Wade - cwade@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81
July 23, 2020 10:53 am CDTShawn Perkins - sperkins@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81
September 9, 2020 4:05 pm CDTCiara 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 4:05 pm CDTShawn 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 3:00 pm CDTUB Central - ubcentral@fsc-corp.org added by Brian Covey - bcovey@fsc-corp.org as a CC'd Recipient Ip: 69.130.248.81