UB Central Information Disclosure Parent
Student's Name: Date of Birth:
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:
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:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: UB Central Information Disclosure Parent
Agree & Sign