Rochester City School District ID: Grade:
Relationship to Student: □ Parent □ Legal Guardian
I am the person legally responsible for the above named individual and I authorize the following:
To obtain only the information from the Rochester City School District as noted below:
By signing below I am stating that:
I hereby authorize the disclosure of educational information between organization(s) or name of person(s) listed above and the Rochester City School District (District), in accordance with the Family Educational Rights and Privacy Act (FERPA The purpose of this disclosure is to advance the education of my student.
I understand that the information disclosed will be provided to the organization(s) or name of person(s) listed above.
I understand that I have the right to revoke and/or restrict this authorization at any time without penalty, provided that I submit a request in writing to the District’s General Counsel. Any revocation shall not apply to the extent the District has already taken action in reliance on this authorization.
I authorize the periodic, on-going disclosure of the above information. This authorization expires on August 31, 2025.
Please be sure to date this form in order for the District to process.