Sample parent authorization form that may be used for obtaining permission to release student records to the University of California

Sample parent authorization form that may be used for obtaining permission to release student records to the University of California.

AUTHORIZATION TO RELEASE STUDENT RECORD INFORMATION

TO THE UNIVERSITY OF CALIFORNIA

PLEASE DETACH AND RETURN

THIS ACKNOWLEDGMENT STATEMENT

TO YOUR CHILD’S SCHOOL

Student’s Name:__________________________________________________

School:_________________________________________________________

Grade Level:_____________________________________________________

I hereby authorize my child’s school to release student record information, including transcripts, to the University of California. I understand that only University of California personnel and their authorized agents will have access to my child’s student record. Student information, including names and addresses, will not be given to others for any purpose; this information will be utilized only by the University of California to determine my child’s eligibility status for the new Eligibility in the Local Context (ELC) program, to evaluate the ELC program, and to invite students to apply to the University of California.

I understand that signing and returning this authorization does not guarantee that my child’s transcript will be submitted to the University of California for the purposes of ELC evaluation.

__________________________________________________________________

Signature of Parent or Guardian Date