24/25 Authorization For Release of Confidential Information

Authorization For Release of Confidential Information
As noted below the following are authorized to:*

Disclose InformationReceive InformationExchange Information
Regarding (Student Full Legal Name)*

First NameMiddle NameLast Name
Student Date of Birth*

MonthDayYear
Date
From: *
Organization/School you would like to request records from
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
To: *
(Who should receive records)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Information to be Disclosed*

Academic records and transcriptsEducational and/or psychological evaluationsMedical / School Nursing RecordsDiscipline & behavior information / records if availableCorrespondenceIEP/504Other
Parent/Guardian Consent & Signature
I, name of parent/legal guardian* hereby authorize the release of records indicated above for the name of student individual listed above.

I hereby authorize the release of the requested records and understand that the information obtained is to be treated in a confidential manner as afforded by the provisions of the Family Education Rights and Privacy Act (FERPA). FERPA prohibits disclosure of personally identifiable information without consent except in limited circumstances. *Please note that any health and/or medical information being released is protected under FERPA privacy standards and not the Health Insurance Portability and Accountability Act (HIPAA).

I herewith release and hold harmless King's Academy and any of its agents, employees, directors, or volunteers from any liability for the release of any information provided in accordance with this directive.

I understand that my consent for the release of records is voluntary and I can withdraw my consent at any time in writing. Should I withdraw my consent, it does not apply to information that has already been provided under the prior consent for release.

This release is valid for one year from the date the authorization is signed.
Parent/Guardian Full Legal Name*

First NameMiddle NameLast Name
Signature of parent/legal guardian*
Date:*

MonthDayYear
Date
Should be Empty:

Authorization For Release of Confidential Information

Parent/Guardian Consent & Signature