Dane County Shelter Home____________________
2402 Atwood Avenue Madison, WI 53704 Phone 608 246- 3889 Fax 608 245-3651
Family Education Rights and Privacy Act Release Form
Student’s Name (Please Print):
I, the undersigned, hereby authorize
to release in
writing or verbally the following educational records and information (identify records or types
of records below):
School academic, behavioral, disciplinary, and attendance records.
These records should be released to the following agency (identify name and address of agency
to receive information):
Dane County Juvenile Shelter Home
2402 Atwood Avenue
Madison, WI 53704
These records are being released for the purpose stated below:
School academic, behavioral, and attendance checks on juvenile listed above.
I understand that by signing this authorization, I am voluntarily waiving my rights of
nondisclosure of my child’s education records under federal law only as to the person(s) or
agency(ies) specifically listed. This release does not permit the disclosure of these records to
any other person(s) or entities without my written consent.
I understand that I am not required to release my child’s education record to anyone and that
this release remains in effect until I revoke it.
Student Signature:
Date:
Signature of Parent/Guardian:
Date: