SPAULDING HIGH SCHOOL UNION DISTRICT #41 CODE: JRA-E
POLICY MANUAL
1st Reading: 12/4/00,2/5/01
2nd Reading; 1/4/01,3/5/01
3rd Reading: 4/2/01
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Parental Permission for the Release of Personal Identifiable Information


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.

I. Student’s Name _____________________________________

II. Records to be disclosed:




III. The purpose of this disclosure is:




IV. 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)