SPPS Release Form

CONSENT TO RELEASE and OBTAIN PRIVATE STUDENT DATA

Community Partner of Saint Paul Public Schools

Students Name

Birthdate (MM/DD/YY)

Date

Grade

Student ID #

Parent/Guardian Name

Address

City, State Zip code

I authorize Special School District No. 625, Saint Paul 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 academic and non-academic time, and allow secured on-line access to student data and obtain on-line reports of interventions and interactions

Name of Organization or Person: Address:

Name of Organization or Person

Address

City, State Zip code

The information to be released is listed below. Please provide consent by initialing next to each line item below:

Information: Student name, date of birth and school name

Write your initials here

Attendance: Including daily and period attendance for the current school year and reasons for

Write your initials here

Special Status: Including if a student has an IEP or 504 Plan or receives Language learner services

Write your initials here

Demographic: Including gender, home language and race/ethnicity

Write your initials here

Classes and Grades: Including progress marks and final grades, credits received and GPA Demographic: Including gender, home language and race/ethnicity

Write your initials here

Enrollment/schedule: Including student enrollment history, current class schedule and teachers to scheduled courses

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

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

Write initials here

1. I understand that this consent takes effect the day that I sign it.

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):

Signature

Clear