Consent for Release of Education Records

Completion of this document authorizes the disclosure and use of education records as described below. Completion also authorizes you to discuss this information with representatives of the organization named below entitled to receive said information. If you have any questions regarding this form, please email the Director of Student Information Services, Ms. Khuloud Hajjiri Assaf at khajjiri@acsamman.edu.jo.

Student Information

Student's First Namerequired

Student's Last Namerequired

Date of Birthrequired (mm/dd/yyyy)

Date Enteredrequired (mm/dd/yyyy)

Graderequired

Schoolrequired

Parent/Legal Guardian or Student 18 and aboverequired

Relationship to Studentrequired

Use and Disclosure Information

Use and Disclosure*

I, the undersigned, do hereby authorize The American Community School, Amman to disclose and deliver the complete education records maintained under the above student’s name including but not limited to the following: Grades and transcripts, Psychological & Educational Testing, Verbal Information, School Health Records, Special Education Records, Discipline.

Records not to be disclosed

Please list any records you do not wish to be disclosed (choose all that apply):

Delivery Options

The education records described above shall be released to the following:

Namerequired

Organizationrequired

Email Addressrequired

Authorization and Approval

Authorization*

The electronic signature below gives my voluntary authorization for the use, disclosure and/or redisclosure of the information identified above. I understand that the information to be disclosed or redisclosed may include individually identifiable health information. I understand that, upon my request, I am entitled to a signed copy of this authorization form and the records to be disclosed. Unless sooner terminated in writing, this release shall remain effective for 1 year from the date signed below. A copy of this release shall be as sufficient to authorize release of information identified above as the original signed by me.

Signature of Parent/Legal Guardian or Student (18 and above)required

Relationshiprequired

Daterequired (mm/dd/yyyy)

Email Addressrequired