MSPS Consent

Student's Last Name

Student's First Name

Birthdate (MM/DD/YY)

Date

Grade

ID #

School ID

Parent/Guardian Name

Address

City

State

Zip code

I authorize Special School District No. 1, Minneapolis Public Schools, to release written and verbal information to, obtain written and verbal information from, to allow the agency/person to schedule a time with the school to see the student at school during non-academic time, and allow secured on-line access to student data and obtain on-line reports of interventions and interactions from:

Name of Organization or Person

Name of Specific Program at Organization

Address

City

State

Zip code

The information to be released will be student name, address, telephone, photograph, date of birth, dates of attendance, grade, current school, student ID, and the information I initial below:

Attendance: Including daily and period attendance for the current school year, reasons for absences, summary information by course for the school year, summary attendance data for the student’s entire time with MPS

Write in your initials here

Classes and Grades: Including skills report cards, courses taken and grades given, credits received and GPA

Write in your initials here

Demographic: Including gender, home language, ethnicity, resides with name and contact information

Write in your initials here

Removals & Suspension: Including infraction date, action type and days, for the current school year

Write in your initials here

Enrollment/Schedule: Including student enrollment history, current courses enrollment, teachers assigned to the courses, teacher contact information

Write in your initials here

Homework: Including homework assignments and scores, assignment status (missing, complete), in-class tests

Write in your initials here

Special Status: Including if a student has/is an IEP or 504 Plan, English as a Second Language Learner, and/or Go-To-Cards

Write in your initials here

Test Scores: Including scores for state mandated or district wide tests

Write in your initials here

All other educational data necessary for the agency to provide service to the named student.

Write in your initials here

1) I understand that this consent takes effect the day that I sign it. It expires on

Month/Day/Year

You can leave blank if you choose.

or one year from the date of my signature.

2) I may change this consent at any time by sending a written notice to the releasing agency.

3) School officials may disclose this information if authorized or required by law to do so. A photocopy of this completed form is as valid as the original.

Parent Signature (or Student, if of legal age)

Clear

Month/Day/Year

Parent Signature (or Student, if of legal age)Month/Day/Year Signed release does not guarantee access to student data through the Community Partner Portal. Final access is at the discretion of Minneapolis Public Schools.

MINNEAPOLIS PUBLIC SCHOOLS