top of page
OBH Logo Full Color Dark.png
Call Now
OBH Logo Full Color Dark.png

CONSENT FOR RELEASE OF EDUCATION RECORDS

AUTHORIZATION FOR USE AND/OR DISCLOSURE OF EDUCATION RECORDS

The Family Educational Rights and Privacy Act (FERPA) is a federal law that protects the privacy of student education records created or maintained by a school that receives federal funds. Completion of this document authorizes the disclosure and use of education records as described below. Completion also authorizes you to discuss this information with representatives of the organization named below entitled to receive said information.

CONSENT FOR RELEASE OF EDUCATION RECORDS

Student Information

Date of Birth
Month
Day
Year
Use and Disclosure Information
I, the undersigned, do hereby authorize (the school listed) to disclose and deliver the complete education records maintained under the above student’s name including but not limited to the following:

The education records described above shall be delivered to:

Please list any records you do not wish to be disclosed:

AUTHORIZATION FOR REDISCLOSURE: Under federal law, the requestor (School District) may not redisclose the information identified above to any other party without your prior consent. If you wish to authorize the School District to redisclose the information identified above please mark the box below: I authorize the School District to redisclose the education information described above and I understand that if the information is redisclosed it may not be protected by federal privileges, privacy laws or regulations.


APPROVAL: My authorization for the use, disclosure and/or redisclosure of the information identified above is voluntary. I understand that the information to be disclosed or redisclosed may include individually identifiable health information. I understand that, upon my request, I am entitled to a signed copy of this authorization form and the records to be disclosed. Unless sooner terminated in writing, this release shall remain effective for 1 year from the date signed below. A copy of this release shall be as sufficient to authorize release of information identified above as the original signed by me.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date
Month
Day
Year
bottom of page