FERPA Release Form

1
My Name
First Name
Last Name
2
Phone NumberMy Phone Number
Please enter a valid phone number.
3
My School, College, Technical School, or University
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Large
Normal
Small
Ok
Ok
4
I Authorize My School To Speak With Orchard Human Services, Inc. StaffI authorize my school to speak with Dr. Darleen Claire Wodzenski and other Orchard Human Services, Inc. Staff about all aspects of my school life including academic, financial, disability-related, and learning support.
YESNO
5
I Authorize Orchard Human Services, Inc.'s staff and/or representatives to speak with my school's or university's staff and administration I authorize Orchard's staff to speak with my school/college/university to share enough information to support my ongoing mental and emotional health and wellbeing, enrollment, education, career, and financial issues including financial aid.
YESNO
6
Date
Date
Year
Month
Day
7
Signature
Should be Empty: