The Wyoming Department of Education (“WDE”) would like to collect data on activities and events taking place in classrooms, schools, and school related programs throughout the state. The Family Educational Rights and Privacy Act (“FERPA”) requires the WDE and 21st Century Community Learning Center (“21st CCLC”) to obtain prior written consent from the parent, guardian, or eligible student before releasing calculate the impact the 21st CCLC has on student performance and to meeting reporting requirements as a result of receiving state and federal funds.

Sheridan County School District #2, 21st CCLC is dedicated to establishing an after school program designed to provide students with academic and enrichment opportunities, as well as additional activities to compliment their regular academic programs. Quality programs are those that demonstrate a high daily attendance rate and engagement with family members of active participants. Programs that demonstrate these characteristics are more likely to have higher student growth, increased passage rates of local and state assessments, and students pursue post-secondary educations.

I understand that this authorization is made pursuant to the Family Education Rights and Privacy Act (“FERPA”), set forth in 20 USC §1232g and its regulation in 34 CFR Part 99.30(a), which requires that (1) parent or eligible student’s consent specify the record to be disclosed, (2) state the purpose of the disclosure, and (3) identify the party or parties to whom the disclosure may be made.

By signing this form, I grant the school my student attends permission to disclose to the 21st CCLC the following information. I also grant permission to the 21st CCLC to re-disclose the following information to the re-disclosure parties.

Records Disclosure: School Registration Information/Demographic Data, Assessment Data, Student Grades, School Day Attendance, Survey Data, Free and Reduced Lunch Status, Attendance Data Student Grades, Assessment Data, Demographic Data

Disclosure Parties: 21st CCLC

21st CCLC Re-disclosure Parties:
Wyoming Department of Education
WDE contracted statewide evaluator and District contracted evaluator
United States Department of Education

Purpose of Disclosure: Collect data to calculate the impact 21st CCLC has on student performance

All records and information regarding services will be protected by FERPA, which governs the exchange of confidential information. The exchange of information will be limited to the authorized staff of the 21st CCLC and the aforementioned re-disclosure parties. No individual student data will be released beyond that which is specified in this authorization.

This authorization, to receive services from the 21st CCLC and to exchange confidential information, shall remain in effect for the period of my student’s enrollment in the 21st CCLC, or until rescinded in writing. I understand that this release may be revoked by me at any time with a written request dated and signed by me, except to the extent that the 21st CCLC has already acted in reliance upon this consent. Written revocations shall be sent to:

Yvonne Osborne
Sheridan County School District #2,
201 N Connor, Suite 100, Sheridan, Wyoming 82801
307-461-2866 (phone)
yvonne.osborne@scsd2.com

I understand the 21st CCLC program requires ten (10) business days to process my request. I understand that personal records are protected by FERPA and any additional disclosure or re-disclosure, not authorized by this consent or otherwise permissible pursuant to federal or state law, is prohibited.