Authorized Access and Disclosure Form
Required for Students 18 and Over if parent access is requested.
Name of Parent or Student (18+) on Account
*
First Name
Last Name
Email
*
example@example.com
I give authorization to disclose information and/or speak to the following person(s): Name:
*
First Name
Last Name
Name
First Name
Last Name
I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange) of the following information to the above named party(ies) by ArchwayOnline.
*
Any & all records on file
Student name / date of birth(DOB) / grade level / enrollment status
Transcripts
Testing Scores (ACT/SAT/PSAT and received records)
Course Titles / Course Texts/Resources / Course Notes / Grades / Credits
Portfolio
Independent Education Plan (IEP) or equivalent
Immunization records/exemptions
Health records
Records of Payments
Family contact information
Records from previous school(s)
Speaking to mentors, counselors, teachers for ArchwayOnline
Other
For:
*
All students on account
For Adult Student (18+)
For Specific Student(s) on account (list below)
Specific Student(s)
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: