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Exhibit 5–4: Sample Consent Form to Allow Accompanying Person to Review Record

(For Use by Parent or Eligible Student to Grant Consent)

I hereby grant permission for [name of person] _________________________ to accompany me today during my review of my/my child’s education records. I understand that in doing so, the information maintained in the education records, otherwise protected by the Family Educational Rights and Privacy Act (FERPA) [and state laws, if applicable], may be disclosed with my consent to the above individual.

Signature:_________________________

Name: _________________________

Date: _________________________
 

For Use by Accompanying Person as Affidavit of Nondisclosure

In accompanying the above-signed parent/guardian on this date during his/her review of the education records of: _____________________, I will be given access to confidential information maintained in the records of the named student. I understand that this information is protected under FERPA [and state laws, where applicable]. I hereby acknowledge that I fully understand that the intentional release by me of this information to any unauthorized person could subject me to [penalties, where applicable] imposed by FERPA [and state laws].

Signature: _____________________

Name: _________________________

Date: _________________________
 

For Official Use Only

Staff Initials: ______________________

Date: ______________________

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