Sample parent authorization form to release student records to 
UC for ELC Program.


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