Consent to Access Family Information

CONSENT TO ACCESS FAMILY INFORMATION FORM

The Children’s Services Council of Leon County (CSC Leon) provides funding to make various children centered programs, available and affordable to families throughout Lyon county. To determine if these programs positively impact children’s lives, CSC Leon collects information about your child’s experiences and behavior to measure both short and long-term outcomes. CSC Leon follows strict data privacy protections for information collected in accordance with the Family Educational Rights and Privacy Act (FERPA) guidelines. Directly identifying information (e.g. names, addresses) will be safeguarded and maintained under strictly controlled conditions. You will never be identified in any publication from this work.
Please check the appropriate permissions and sign below:
Do you give permission to the Children Services Council of Leon County to access your child’s academic and disciplinary records to determine if this program has a positive impact on my child’s academic performance or behavior?
If so, please enter your child’s Leon County Schools Student ID Number
Another school (please name
Do you give permission to the Children’s Services Council of Leon County to access your child’s records with the Department of Juvenile Justice to determine if this program has been a positive impact on your child?
Do you give permission to the Children’s Services Council of Leon County to access your child’s records with the Department of Children and Families to determine if this program has been a positive impact on your child?
Name

Child First NameLast Name
Name

Parent/Guardian First NameLast Name
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
*Please note: the student ID number is available on the Leon County Schools parent portal or by calling your child's school.

This consent is valid for 48 months from date of signature unless revoked in writing.
Should be Empty:

CONSENT TO ACCESS FAMILY INFORMATION FORM