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.