Content Exchange form

Student Name

First Name

Last Name

Student Birth Date

YYYY

Form in which information may be exchanged:

Receive Information from:

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Release Information to:

Notre Ecole, 5920 Golden Valley Rd, Golden Valley, MN, USA info@notreecole.org 952 229 1097

Disclosed Information is limited to:

Other ( please specify):

Purpose for Disclosure

Other ( please specify ):

I understand that his information will become part of the student’s educational record. I understand that information authorized by this consent has been disclosed from records whose confidentiality is protected by Federal Regulations (42CRF Part 2). Federal regulations prohibit disclosure of this information except when there is specific written consent of the parent/guardian of the person to whom the information pertains, unless otherwise stated in the regulations. A general authorization for the release of information is not adequate for this purpose. I understand that records are protected under Federal and State Confidentiality Regulations and cannot be disclosed without written consent unless otherwise provided for in State and Federal regulations. The information used or disclosed in conjunction with this authorization may be subject to redisclosure by the recipient and no longer protected by these rules. I also understand that I may revoke this consent at any time except to the extent that action based on this consent has been taken.

Agreement

yes

This consent will expire one year from the date of approval, or upon receipt of a written revocation notice or as below

Name of person Authorized to provide consent (parent, guardian, self)

First Name

Last Name

Date of signature

YYYY

Content Exchange form

©2020 NOTRE ÉCOLE

Action

Info