I, _____________________________, parent/guardian of_______________________________, hereby authorize ___________________________________________________ to release to the [NAME OF ATTORNEY OR ORGANIZATION] all education records or documents of any kind in its possession related to the student listed below, for whom I am the educational rights holder. This authorization extends to [NAMES OF ALL INDIVIDUALS WHO MAY SUBMIT REQUEST OR RETRIEVE RECORDS]. Records may include, but are not limited to: disciplinary and behavioral reports, evaluations and assessments, Individual Education Program reports and related documents, Section 504 Plans and related documents, police reports, incident reports, standardized test scores, grades, schedules, attendance records, any handwritten and/or typed memos or notes regarding the student, and any communications to the guardian regarding the student. I further consent to your discussion of these documents and the contents of them with the Loyola Law Clinic.
I understand that the purpose of this release is to permit [NAME OF ORGANIZATION OR ATTORNEY] to investigate and/or advocate for my legal rights.
I also authorize [NAME OF ATTORNEY OR ORGANIZATION] to release my confidential records and information to other individuals and entities as necessary to investigate and/or advocate for my legal rights. I understand that these third parties are also bound by confidentiality. [NAME OF ATTORNEY OR ORGANIZATION] will otherwise keep the records and information confidential.
I understand that I may revoke this consent to release information at any time, except to the extent that action has already been taken. If not revoked earlier, this consent shall terminate two years from the date of signing.
A copy of this signed form is as valid as the original.
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Student’s Name Student Date of Birth
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Signature of Legal Guardian/Educational Rights Holder Date of Signing
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Printed Name of Legal Guardian Relationship to Student
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Address of Legal Guardian