Certification and Authorization to Release Information and Records

I/we certify that all the information provided is true and correct.  I understand that information provided may be verified to help determine my child’s eligibility for the program. I authorize the release of student records required for the eligibility and participation in the Friendly House, Inc. Educational Talent Search program. These records shall include but are not limited to all transcripts (including special education and English Language Learner Program), grade point average, progress reports, attendance, withdrawal, standardized test scores, class schedules, and free or reduced lunch eligibility. These documents and all information will be held in strictest confidence by Friendly House, Inc. Educational Talent Search (ETS) and its staff.

I, the undersigned, do hereby consent and agree that Friendly House, Inc., its employees, or agents have the right to take photographs, videotape, or digital recordings and to use these in any and all media, exclusively for the purpose of TRiO/ETS activities (i.e. field trips, summer programs, etc.) and Friendly House, Inc.

Certification

Student Information (To determine eligibility) 

Family Information (To determine eligibility) 

Self-Attestation Statement

I certify that the information given on this document is true and accurate to the best of my knowledge and belief.  I understand that such information is subject to verification, and I further realize that falsified or fraudulent information may result in rejection of this document and subsequent termination from the Friendly House TRIO Educational Talent Search program.