REQUEST/PERMISSION FOR
DISCLOSURE OF STUDENT RECORDS
Name of Student ___________________________________________________
SSN_______________ GRADE _____ D.O.B. (mm/dd/yyyy)__________
Name of School ___________________________________________________
Address ___________________________________________________
Parent’s/Guardian’s Name(s) ___________________________________________________
Last Date of Attendance ____________________
A. REQUEST
Request by Janice Mitchell Isbell Academy for Release of the following records: All permanent records, test results, health records, special education records, (if any), and all other records.
Purpose: (If request is made by other than parent/eligible student) Establishing academic records for student who is enrolled at the Isbell Academy.
If a third party, I understand that this information must not be disclosed to any other party without the prior written consent of the parent of the student or the eligible student; except, that which is disclosed to an institution, agency or organization many be used by its officers, employees and agents, but only for the purpose stated above.
Signature: ___________________________________________________
Title: _______________________________
B. PERMISSION Required when disclosure is made to a third party.
I hereby give my permission for the disclosure of records as requested above.
Signature: ___________________________________________ Date: _________________
JMIA FORM 4, 7 AUG 2001