Authorization for Release of Information

Authorization to Release/Receive Educational Records and/or Communicate with Outside Agencies/Individuals.

Section I: Student & Parent Information
This form provides authorization release/receive (check one) educational records and information relating to:

This form provides authorization release/receive (check one) educational records and information relating to: Release Receive
Student Name: Student Name: First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Student Date of Birth Student Date of Birth / MM / DD YYYY
Phone Phone - ### - ### ####
Email
Was student retained due to 3rd Grade Reading Guarantee?

Was student retained due to 3rd Grade Reading Guarantee? Yes No
Is student retained but recommended for 4th Grade classes and mid-year promotion?

Is student retained but recommended for 4th Grade classes and mid-year promotion? Yes No
Middle School Scheduling Preferences

Please answer the following questions ONLY if your child is enrolling in grades 6, 7 or 8. These answers will give the guidance counselor an idea of a possible schedule for your student.
Music Choice
What MATH CLASS is your child currently enrolled in?

Has this student taken any of these classes this year?
	Yes	Sem 1	Sem 2	No
Art	ArtYes	ArtSem 1	ArtSem 2	ArtNo
Health	HealthYes	HealthSem 1	HealthSem 2	HealthNo
Physical Education	Physical EducationYes	Physical EducationSem 1	Physical EducationSem 2	Physical EducationNo
Technology	TechnologyYes	TechnologySem 1	TechnologySem 2	TechnologyNo

High School Athletics
Does your student participate in a High School sport?

Does your student participate in a High School sport? Yes No
Please list the sport(s) your student participates in.
Section II: Disclosure and Use of Educational Records/Personally Identifiable Informational

In this section you need to provide the contact information for the agency/individual from whom BCSD will contact for your child's records.
Name of Agency/Individual (previously attended school)

This information pertains to the school or institution that your child previously attended.
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
To disclose educational records for the above-referenced student and information in the manner described below. To communicate and share personally identifiable information as described below.
Section III: Description of Educational Records/Personally Identifiable Information to be Disclosed.

Check the educational records or information you are authorizing to be disclosed:
All Educational Records Academic Records/Transcript of Credits and Grades Test Scores Attendance Records Health Records Evaluation Team Reports and Supporting Data/Assessments Individual Education Plans and Related Progress Reports 504 Plan/504 Evaluation Gifted/Talented Program Information Immunization Records Limited English Proficient Records Other pertinent information (describe below)
Section IV: Persons Or Entity Authorized to Receive Information

The District has my permission to communicate with and release the information described above to:
Name of Receiving School
Section V: Purpose Of this Authorization

The purpose of this disclosure of educational records or personally identifiable information is:
To aid in making present and future educational decisions Other: Other:
Section VI: Expiration and Revocation

This authorization may be revoked (canceled) at any time except to the extent that the district has already released personal health and/or other personally identifiable information prior to the revocation of this authorization. Requests for revocation must be in writing. To revoke the authorization contact Dr. Stephanie Morgan, Director of Student Services, at smorgan@bcsoh.org. If not revoked, this authorization will expire one year after the date on which the authorization is signed/submitted.
Section VII: Signature And Acknowledgement
Acknowledgement

Acknowledgement I acknowledge that this authorization is voluntary I acknowledge that I will receive an email that contains a copy of this form for my records I acknowledge by submitting this form it is my electronic signature
Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
If a personal representative (for example, a spouse, parent, legal guardian, etc.) signs this form on behalf of the individual identified in Section I, please complete the following:
Name Name First Last
Date Date / MM / DD YYYY
Relationship to student:

Authorization for Release of Information

Authorization for Release of Information

Section I: Student & Parent Information

Middle School Scheduling Preferences

High School Athletics

Section II: Disclosure and Use of Educational Records/Personally Identifiable Informational

Section III: Description of Educational Records/Personally Identifiable Information to be Disclosed.

Section IV: Persons Or Entity Authorized to Receive Information

Section V: Purpose Of this Authorization

Section VI: Expiration and Revocation

Section VII: Signature And Acknowledgement

If a personal representative (for example, a spouse, parent, legal guardian, etc.) signs this form on behalf of the individual identified in Section I, please complete the following: