JRA-E(1) Student Records

Code: JRA-E(1)

REQUEST FOR DISCLOSURE OF STUDENT EDUCATIONAL RECORDS

(Completed form to be retained, on file with student

records, by appropriate school district administrator

cooperating in this disclosure request).

______________________________ Name of Organization or Agency Making  Disclosure Request

______________________________ Signature of Representative or Person              Making Disclosure Request

______________________________ Date of Report

______________________________ Student Name

______________________________ Description of Student Records for Which Disclosure Request is Made

Statement of Relationship or Description of Legitimate Educational Interest of Person Making Disclosure Request:  ____________________________________________________________________ ________________________________________________________________________________________________________________________________________

AUTHORIZATION FOR DISCLOSURE

Permission is hereby granted to (school official) ______________________________ to disclose the educational records of (student name)_________________________.  I understand that the educational records will be examined by ____________________________________________, and certify that I am fully authorized to grant permission for this disclosure.  My relationship with the named student is:  ___________________________________________________________.

___________________________________________________________

 (Signature of Person Authorizing Disclosure)                                   (Date)

RECORD/REPORT OF DISCLOSURE OF STUDENT EDUCATIONAL RECORDS

____________________________________ Date of Disclosure

Statement of Examiner:  "I certify that I have, on this date, examined the educational records of (student name)_______________________________________, and that I have been advised that the disclosure of the information to a third party, without prior consent, is prohibited." 

_____________________________________________  __________

(Signature of Examiner)                                                              (Date)

Adoption Date: 5/15/14

Amended: 3/21/17