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
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: September 28, 2023
Please print students' Name, Current School and Grade:
Student's Current SchoolAcademy @ ShawneeAlex R Kennedy ElementaryAtherton High SchoolAtkinson AcademyAuburndale ElementaryBallard High SchoolBates ElementaryBlake ElementaryBloom ElementaryBlue Lick ElementaryBowen ElementaryBreckinridge-Franklin ElementaryBrown SchoolButler Traditional High SchoolByck ElementaryCamp Taylor ElementaryCane Run ElementaryCarrithers Middle SchoolCentral High SchoolChancey ElementaryChenoweth ElementaryCochran ElementaryCochrane ElementaryColeridge-Taylor Montessori ElementaryConway Middle SchoolCoral Ridge ElementaryCrosby Middle SchoolCrums Lane ElementaryDixie ElementaryDoss High SchoolDunn ElementaryDuPont Manual High SchoolEastern High SchoolEisenhower ElementaryEngelhard ElementaryFairdale ElementaryFairdale High SchoolFarmer ElementaryFarnsley Middle SchoolFern Creek ElementaryFern Creek High SchoolField ElementaryFoster Traditional AcademyFrayser ElementayFrederick Law Olmsted Academy NorthFrederick Law Olmsted Academy SouthGilmore Lane ElementaryGoldsmith ElementaryGreenwood ElementaryGutermuth ElementaryHartstern ElementaryHawthorne ElementaryHazelwood ElementaryHighland Middle SchoolHite ElementaryIndian Trail ElementaryIroquois High SchoolJacob ElementaryJeffersontown ElementaryJeffersontown High SchoolJohn F Kennedy Montessori ElementaryJohnsontown Road ElementaryJohnson Traditional Middle SchoolKammerer Middle SchoolKenwood ElementaryKerrick ElementaryKing ElementaryKlondike Lane ElementaryKnight Middle SchoolLassiter Middle SchoolLaukhuf ElementaryLayne ElementaryLouisville Male High SchoolLowe ElementaryLuhr ElementaryMarion C. Moore High SchoolMaupin ElementaryMcFerran Preparatory AcademyMedora ElementaryMeyzeek Middle SchoolMiddletown ElementaryMill Creek ElementaryMinors Lane ElementaryNewburg MiddleNoe MiddleNon-JCPSNorton Commons ElementaryNorton ElementaryOkolona ElementaryPleasure Ridge Park High SchoolPortland ElementaryPrice ElementaryRamsey Middle SchoolRangeland ElementaryRobert Frost Sixth Grade AcademyRoosevelt-Perry ElementaryRutherford ElementarySanders ElementarySemple ElementarySeneca High SchoolShacklette ElementaryShelby Traditional AcademySlaughter ElementarySmyrna ElementarySouthern High SchoolSt Matthews ElementaryStonestreet ElementaryStopher ElementaryStuart AcademyThomas Jefferson MiddleTrunnell ElementaryTully ElementaryValley High SchoolWaggener High SchoolWatson Lane ElementaryWatterson ElementaryWellington ElementaryWestern High SchoolWestern Middle School for the ArtsWestport Middle SchoolWheatley ElementaryWheeler ElementaryWilder ElementaryWilkerson ElementaryWilt ElementaryZachary Taylor Elementary
Student Grade LevelPre-KKindergarten 123456789101112
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.
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Document Name: 19-04-22 JCPS Authorization to Release Education Records and Consent Form
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