Consent to Disclosure of School Student Records and Information

I hereby grant my consent for Dekalb Community Unit School District No. 428 (the “District”) and its Board, administrators, employees, attorneys, and agents to freely communicate with and release records and all of the information set forth below to the parties identified below:

Recipient: Kishwaukee College- Trio Upward Bound (815)825-9437

 

Information that may be Disclosed:

1. The complete student record of and any student information for {main_name}, including but not limited to any documents created by the District pursuant to the Illinois School Student Records Act , 105 ILCS 10/1 et seq .

2. Individualized Education Plans (IEP’s) and Section 504 Plans, including those which may contain mental health records under the Illinois Mental Health and Developmental Disabilities Confidentiality Act , 740 ILCS 110/1 et seq.

The purpose for this disclosure is for Kishwaukee College- Trio Upward Bound. If I do not grant this consent, these records will not be released to the recipients, but I will not suffer any other consequences.

This consent is valid until {studentsGraduation} and may be revoked at any time in writing.

I also understand that I have the right to inspect and copy the information to be disclosed pursuant to this consent.

Note: If the student is under age 12, only the parent’s signature is needed. If the student is between ages 12 and 18, both the parent’s and student’s signature are needed. If the student is age 18 or over, only the student’s (or if the student has been judged to be incapacitated by a court, the guardian’s) signature is required.