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Barre Town Supervisory District Policy Manual

TITLE: Parental Permission for the Release of Personal Identifiable Information     CODE: JRA-E

To Parent/Guardian/Educational Surrogate or Adult Student:

If you sign this form, you are giving your permission for the release of records and/or information from your child's (or your) school record. Therefore, if you do not understand any part of this form, please contact your school's staff or the superintendent's office.

  1. Student's Name _____________________________________

  2. Records to be disclosed:

  3. The purpose of this disclosure is:

  4. Records may be disclosed to the following party or class of parties:

____ I willfully give my permission for the school district to release the above described records.

____ I do not give my permission for the disclosure of the above described records.

 

 
_____________________
Date
 

______________________________________
Signature
(Parent/Guardian/Education Surrogate Parent or Adult Student)

 

c:Mac

 

1st Reading: 6/7/00
2nd Reading/Date Adopted: 6/21/00
Date Revised:
Date Effective:
Legal Reference(s):
Cross References:
Date Distributed: