19-04-22 JCPS Authorization to Release Education Records and Consent Form


Administrative Offices 
P.O. Box 34020
Louisville, KY 40232-4020
(502) 485-3011
Fax: (502) 485-3991

 

Community Partner Learning Place
Authorization to Release Education Records and Consent Form

The students listed below are participating in the programs at the Louisville Urban League, located at 1535 W Broadway, Louisville, KY or other identified site hereafter referred to as the Organization. By signing this form, I am giving the Organization staff permission to communicate regarding services offered to me and/or my family, with the Jefferson County Public Schools (JCPS). I hereby authorize JCPS to release the education records of the students listed below to the Organization. The records to be released are the student’s name, student JCPS ID number, school, grade level, State required assessment scores, district assessment scores, grades, attendance, suspensions, kindergarten readiness, transition readiness, and ACT scores for the current and prior school years. I understand that the Organization has agreed to keep these records confidential.

I understand that by authorizing the release of this information, it will be used for the sole purpose of providing and enhancing services to me, my family, and/or my child and to avoid duplication between the agencies. The disclosure of information will be limited to staff at the Organization and JCPS.

There may be times when JCPS, the Organization or the news media may take photographs (or other digital images) of students participating in activities. Those images may appear in JCPS’s or the Organization’s publications including electronic publications or in the news media for education related stories. By signing this form, I authorize JCPS and the Organization to use the name and image of the students listed below for these purposes and for the purpose of providing community recognition.

I understand that JCPS and the Organization are independent parties. I understand and agree that JCPS shall have no liability for the acts or omissions of the Organization, their employees and volunteers. I have read and understand the contents of this form. I have received a copy, and I agree to its provisions. I understand that I may revoke this authorization at any time by written request.

I understand that this authorization will remain in effect for the current school year or until revoked by me in writing and delivered to the address below.

Print Name of Parent/Guardian (or Student if 18 or over):

    

Witness Signature: Kish Cumi Price, PhD, Director of Education Policy and Programs   Date: March 1, 2024

Please print students' Name, Current School and Grade:

   

Original must be sent to Krista Drescher-Burke, care of DEP, VanHoose Education Center, 3332 Newburg Road, Louisville, KY 40218, or at [email protected], a copy kept on file at organization/agency and copy given to parent/guardian or eligible student.

www.jcpsky.net
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Document name: 19-04-22 JCPS Authorization to Release Education Records and Consent Form
lock iconUnique Document ID: b273dcde63f2c3f1b954ae18c2ef5dd4e639750f
Timestamp Audit
April 22, 2019 4:26 pm EST19-04-22 JCPS Authorization to Release Education Records and Consent Form Uploaded by Carla Robinson - [email protected] IP 98.100.255.218
June 10, 2019 3:14 pm EST Document owner [email protected] has handed over this document to [email protected] 2019-06-10 15:14:00 - 98.100.255.218
June 12, 2019 5:32 pm ESTCarla Robinson - [email protected] added by Carla Robinson - [email protected] as a CC'd Recipient Ip: 98.100.255.218
August 8, 2019 4:57 pm ESTCarla Robinson - [email protected] added by Carla Robinson - [email protected] as a CC'd Recipient Ip: 98.100.255.218