Return to List of Exhibits and Figures
I understand that upon receipt of the information provided by [name of agency or school] regarding [type of information] about [name of student(s)], the re-release of such information is prohibited by the Family Educational Rights and Privacy Act of 1974, as amended [and cite state and local laws, where applicable]. I acknowledge that I fully understand that the intentional release by me of this information to any unauthorized person could subject me to [criminal and civil penalties, where applicable] imposed by law.
Signature: _________________________________
Name: _________________________________
Title: _________________________________
Organization: _________________________________
Date: _________________________________