Consent Release for Education Records

CONSENT TO RELEASE STUDENT EDUCATION RECORDS

The Family Educational Rights and Privacy Act (FERPA) bars the release of education records without the written consent of the parent

Student Name:

DOB:

Home Address:

Phone Number:

As parent and/or guardian of the named student, I give my consent that the student’s education records and information in same may be disclosed/ released to the following:

Agency(ies) or individual(s) to whom records may be disclosed or released:

Name: Joy Baltrip / Monroe Community Mental Health Authority

Address: 1001 S Raisinville Rd., Monroe, MI

Telephone: 734-384-8395

SPECIFIC PURPOSE FOR DISCLOSURE/RELEASE: Family Subsidy

This authorization is subject to my written revocation at any time and in any event will expire six (6) months from the date hereof.

Signature of Parent/Guardian

Relationship to Student

Email Address

Date

Once submitted, this information will be sent to Janice Byron, who will forward the signed request. Questions can be directed to janice.byron@monroeisd.us.

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