Family Educational Rights & Privacy Act Consent and Release Form Pursuant to the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. §1232g; 34 C.F.R. part 99), the written consent of a parent or eligible student is required before the education records of a student, or personally identifiable information contained therein, may be disclosed to a third party, unless an exception to this general requirement of written consent applies. If a student is age 18 years or older, or is enrolled in an institution of postsecondary education, he or she is an “eligible student” and must provide written consent for the disclosure of his or her education records or personally identifiable information contained therein. I,(Required)the undersigned, hereby authorize Detroit Public Schools Community District (hereafter referred to as the “Institution”) and its authorized representatives to copy or photocopy and release to: Third Party: Student Advocacy Center of Michigan requested materials, documents or the complete and entire contents of the student or financial, academic, personal and all other records held by the Institution relating to:Student Name(Required)Student Date of Birth(Required) Month Day Year These records may include, but are not be limited to, the following: General education records, including grades, credits earned, disciplinary records, and referrals to outside agencies. Special education records such as MET, IEPs, MDRS, and any functional behavior assessments or behavior intervention plans. Treatment information including, but not limited to: diagnoses, services provided, number of sessions, progress, medications with dosages, reports. Any psychological evaluations, psychiatric reports, and/or progress reports. If you would like to authorize the release of additional information, please describe below:Additional Information to ReleaseI further authorize the above Institution and its authorized representatives to discuss the above listed Student’s records with the Third Party. I acknowledge by my signature that I understand that although I am not required to release my/the records to the Third Party, I am giving my consent to release the information. I understand that this release remains in effect until I revoke such consent in writing and the written revocation is delivered to the Institution and is processed. I understand that any such revocation shall not affect disclosures previously made by the Institution prior to the receipt and processing of any such revocation. I agree to hold the above Institution harmless from any and all liability for the release of my records to any entities as specified above or any release of information as requested by accrediting authorities or government agencies. I am...(Required) I am the subject of these records and am eighteen years of age or older. I am the parent, guardian, or custodian of the subject of these records and the subject is under eighteen years of age. Signature(Required)Type NameAddress Street Address City State / Province / Region ZIP / Postal Code Date Month Day Year EmailThis field is for validation purposes and should be left unchanged.
