Record Release Form

SALAMANCA CITY CENTRAL SCHOOL DISTRICT 50 Iroquois Drive Salamanca, New York 14779 www.salamancany.org

District Office 716/945-2403 Prospect Elementary 945-5170 Seneca Elementary 945-5140 Jr/ Sr High School 716/945-2404 Pupil Services 945-5142

CONSENT TO RELEASE/OBTAIN RECORDS The Family Educational Rights and Privacy Act (FERPA) generally bars the release of educational records to third parties without the written consent of the parent. (FERPA allows schools to disclose records, without consent, to certain parties as set forth in the law as well as information that has been designated by the District as “directory” information). I, ______, the undersigned, authorize the release of/access to (Parent/Guardian) my child’s records: ______DOB ______(Student’s Name) Records to be released to or obtained from: Salamanca City Central School District 50 Iroquois Drive, Salamanca, New York 14779 Phone: (716)945-5142; (716) 945-2400 Fax: (716) 945-2148 Please forward the following information: Transcript of records and grades/all academic records Tests Scores Health Records Medical/Hospital Psychological/Social Work Reports (if any) Special Education Reports (if any) Gifted/Talented program information or course content (if any) Any other pertinent information

Previous School District (or Other Medical/Agency/Community Contact if necessary) District or Agency Name (contact): District or Agency Address: City: State: Zip Code: Phone Number: ______Fax: ______

The party receiving/reviewing the student record is NOT authorized to transfer this information to a third party without further consent Parents, students age 18 or older, or students attending a post-high school education institution, are advised they have the right to be notified of the student’s transfer of records to another school; that they may receive a copy of the student’s record if desired, and have an opportunity for a hearing to challenge the content of the record prior to its being sent. Signed: Date:

VERIFICATION OF ACCESS OR RELEASE The records indicated on this form were: released shown To:______on ______Initials ______

Parental approval is not required when authorized school personnel request records.

* In(FAMILY accordance with EDUCATION revised Federal and RIGHTSState Statutes, ANDpermission PRIVACY of the parent or ACTS, adult student FEDERAL is no longer required REGISTER, when authorizedVOL. school41, No. personnel 118 requests and PAGE records. 24673)