WSFCS Data Sharing Parent Permission

CONSENT TO DISCLOSE STUDENT’S EDUCATION RECORDS FROM LEXINGTON MIDDLE SCHOOL FOR RESEARCH PURPOSES
The student named below is a part of the CONNECT 21 After School Enrichment Program at Lexington Middle School. This form allows student Education Records to be disclosed with CONNECT 21 to inform program improvements and case management. Your student’s individual information will never be published or shared with partners outside of this project. Please complete the following form to allow participation in this project.

I/We (Please enter parent name(s) below)
Parent Name(s)*

First NameLast Name
are the parents/legal guardians of (Please enter the student's name below)
Student Name*

First NameLast Name
Student ID (Lunch Number)*
Current Grade (Please provide the student's current grade)*
Date of Birth (Please provide the student's date of birth)*
Gender (Please provide the student's gender)*
Ethnicity (Please provide the student's ethnicity)*
Parent Signature*

Clear
Should be Empty:

CONSENT TO DISCLOSE STUDENT’S EDUCATION RECORDS FROM LEXINGTON MIDDLE SCHOOL FOR RESEARCH PURPOSES