STUDENT WAIVER TO RELEASE
INFORMATION
Under the provision of paragraph 99.30 of the
Family Educational Rights and Privacy Act of 1974, as amended, you have the
right and responsibility to provide written consent to release personally identifiable
information to a person, party or class of parties. Without this form (or a
written equivalent statement), I am not be able to give you job references,
discuss your progress with parents or other family members or share information
about you with anyone else. Please fill
out, print and sign this form if you want to allow me (Dave Marshall) to
discuss your performance with anyone outside of those who need to know at
Name: Date:
If you want to provide any limits on the
release of your information, please list them below. If none are listed, I will assume that there
are no limitations on your permission.
1.
List the Person,
Company, or type of person or organization to whom information may be released.
2.
List the purpose
or any other limits on the release of this information (employment, reference,
etc…).
3.
Specific records
or information that I may release to the above named party (parties) or records
I may not release:
Student signature
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