Osde Form 11 - Consent For The Release Of Confidential Information printable pdf download

STATE OF OKLAHOMA STANDARD FORM

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION

I understand that these records are protected under federal and State confidentiality regulations and cannot be released without written

consent unless otherwise provided for in the regulations. Federal regulations prohibit further disclosure of the records without specific

written consent, or as otherwise permitted by such regulation. I also understand I may revoke this consent in writing at any time unless

action has already been taken based upon this consent and in any event this consent expires one year from the date of signature.

______________________________________________________________________________________________________________

…

AUTHORIZING PERSON --

CHILD

PARENT

GUARDIAN

LEGAL CUSTODIAN

OTHER

request that information concerning:

_________________________________________________________________________________________________________________

NAME OF CHILD

DATE OF BIRTH

SSN

be released and authorize ______________________________________________________________________

NAME OF PERSON OR AGENCY RELEASING INFORMATION

_________________________________________________________________________________________________________________

ADDRESS OF PERSON OR AGENCY RELEASING INFORMATION: INCLUDE STREET ADDRESS/P.O. BOX, CITY, STATE AND ZIP

to release to:

John W. Rex Charter Elementary School

NAME/AGENCY

PO Box 2119

ADDRESS

Oklahoma City, OK 73101

CITY, STATE, ZIP

Student education records and information

the following information: ___________________________________________________________________________________________

KIND AND/OR EXTENT OF INFORMATION TO BE RELEASED

To complete enrollment/application and placement at John W. Rex Charter Elementary School

for the following purpose(s): ________________________________________________________________________________________

If the records to be disclosed are education records (which may include discipline records), they are maintained and released in accordance

with the Family Educational Rights and Privacy Act (FERPA). Parents or eligible students shall be provided a copy of the records to be

disclosed if requested. Redisclosure, except as provided at 34 CFR

99.31, requires prior consent of parents or eligible students.

THE INFORMATION I AUTHORIZE FOR RELEASE MAY INCLUDE INFORMATION AND RECORDS WHICH MAY INDICATE THE PRESENCE OF A

COMMUNICABLE OR NONCOMMUNICABLE DISEASE, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO, DISEASES SUCH AS HEPATITIS, SYPHILIS,

GONORRHEA AND THE HUMAN IMMUNODEFICIENCY VIRUS, ALSO KNOWN AS ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS).

†

NOTARY:

___________________________________________________

(Notary)

Subscribed and sworn to me ___________________ 20 _______

My commission number

(signature of person(s) authorizing release)

_____________________________________

My commission expires _______________________ 20 _______

(date)

Notary Public

(or Clerk or Judge)

†

AGENCY VERIFICATION IN LIEU OF NOTARY:

______________________________________________

___________________________

(staff signature and title)

(date)

OSDE Form 11

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Osde Form 11 - Consent For The Release Of Confidential Information

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