CONSENT FOR RELEASE OF STUDENT INFORMATION

Klamath Center for Education and Training

The Family Educational Rights and Privacy Act (FERPA) of 1974 affords certain rights to students concerning the privacy of, and access to, their educational information. FERPA allows, and the Title II Adult Basic Skills programs will collect, for federal reporting purposes, personal identifiable information (PII) and educational information to enter into the Tracking Of Programs and Students (TOPS) database. This database stores educational progress information and student information for the Workforce Innovation and Opportunity Act (WIOA). Additionally, the Office of Community Colleges and Workforce Development is allowed by FERPA to collect and release personal identifiable and educational information for purposes of data matching for federal WIOA reporting and for educational research. This information includes Social Security Numbers and student ID numbers. Individuals may choose to consent to the release of their educational information for other purposes.

Completing and signing the form below allows the Adult Basic Skills program to collect and release other student information as described below, for the purpose described below.

Authorization for Release of Information Student Information:  Please print clearly. 

ID number:

SSN:

Last Name:

First Name:

MI

Mailing Address:

Street:

City:

State:

Zip:

Email Address:

Email student uses most regularly

Specific information to be released: • Personal identifiable information (PII) 

• Name
• Address
• Birthdate
• Social Security Number (SSN) or Identification Number.
• Education information

• Educational records
• Test results
• Attendance
• Occupation
• Employment training, and
• Education goals and outcomes.

**If you sign this form indicating authorization to release your information, your information will be shared with WIOA partners including, but not limited to, the Oregon Higher Education Coordinating Commission, the Oregon Employment Department, the Oregon Department of Human Services, and the Oregon Department of Vocational Rehabilitation.

**If you sign this form indicating authorization to release your information, your information can be shared with another Oregon Adult Basic Education program should you choose to transfer programs.

I consent to release the above information to the organizations listed above and understand that my consent is voluntary and is not required for my participation in any programs or services. I also understand that I can revoke my consent at any time by completing the Revocation for Release of Information form (available in the K-CET office).

Consent:

Student Signature:

(by typing your name into the box you are providing an electronic signature)

Signature Date:

Parent Signature:

(if Student is under age 18 )

(by typing your name into the box you are providing an electronic signature)

Signature Date: