Special Education-Authorization for Release of Records

Special Education-Authorization for Release of Records

This is an official request for a student's special education records. The information contained in this request should be considered private. Please complete all the information in full and then finalize your request by clicking 'Submit'. PLEASE NOTE: In accordance with the Family Educational Rights and Privacy Act of 1974 and California State Law, Blue Ridge Academy will release to the school named below the student's records requested via this form.
Email: *
Requestor's Name: *
Requestor's Phone Number: *
Name of your School or Place of Employment: *
Reason for Request: *

New School of Attendance Other

*We only mail physical SPED records, emailed records will only be sent if urgent. How would you like to receive the records: *

Emailed Only (Physical SPED records will be mailed out on a later date) Mailed Only
Please Mail documents to: *
Type N/A if not applicable
*We will forward physical SPED records at a later date, we don't house physical records to forwarding schools. Please Email documents to: *
Type N/A if not applicable

*Please upload your Educational SPED Records Request if you are a School/Agency: *

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Cancel of
Educational Institute Authorization

I hereby certify and verify that the named student is requesting enrollment in our school and that my signature below authorizes The Blue Ridge Academy to forward the records for educational use only. I understand that the recipient of the record(s) will use said document(s) for legitimate interests only and that the information contained therein shall not be further transferred or communicated to any other part or agency without the expressed written consent of the current/former student except under authority of Public Law 93-380, Educational Rights and Privacy Act. By clicking 'SUBMIT', I certify this information as complete and accurate. I declare under penalty of perjury that the foregoing is true and correct.
Position/Job Title: *
Requestor's Signature: *
Should be Empty: