Community Learning Place 2020-2021: Authorization to Release Education Records and Consent Form
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Student Last Name *
Student First Name *
Community Learning Place Name and Location *
Authorization to Release Education Records
The student listed above is participating in the community learning place noted above, hereafter referred to as the Organization. By signing this form, I am giving the Organization staff permission to communicate with Jefferson County Public Schools (JCPS) concerning my student and/or my family, and I am giving Jefferson County Public Schools staff permission to communicate with the Organization concerning my student and/or my family. I hereby authorize JCPS to release the education records of the students listed below to the Organization. The records to be released are the student’s name, student JCPS ID number, school, grade level, State required assessment scores, district assessment scores, grades, attendance, suspensions, kindergarten readiness, transition readiness, and ACT scores for the current and prior school years. Please note that during NTI, some data (e.g., attendance, suspensions) may not be available. I understand that the Organization has agreed to keep these records confidential.

I understand that by authorizing the release of this information, it will be used for the sole purpose of providing and enhancing services to me, my family, and/or my child and to avoid duplication between the agencies. The disclosure of information will be limited to staff at the Organization and JCPS.

There may be times when JCPS, the Organization or the news media may take photographs (or other digital images) of students participating in activities. Those images may appear in JCPS’s or the Organization’s publications including electronic publications or in the news media for education related stories. By signing this form, I authorize JCPS and the Organization to use the name and image of the students listed below for these purposes and for the purpose of providing community recognition.

I understand that JCPS and the Organization are independent parties. I understand and agree that JCPS shall have no liability for the acts or omissions of the Organization, their employees and volunteers. I have read and understand the contents of this form. I have received a copy, and I agree to its provisions. I understand that I may revoke this authorization at any time by written request.

I understand that this authorization will remain in effect for the current school year or until revoked by me in writing and delivered to the address below.
Authorization *
Required
Name of Parent/Guardian (or student if 18 or over) *
Date *
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Name of Witness *
Date *
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Name of Student's School *
Grade Level of Student *
Community Learning Place Director Name and Contact Information *
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