RIGHTS OF CONSENT - Galena Park Independent School District



Communities In Schools Afterschool Centers on Education (CIS-ACE)Texas Education Agency RELEASE OF INFORMATION FORMI give permission for the release of information for my son/daughter, ____________________________, a student at Green Valley Elementary in Galena Park Independent School District.I understand that the information collected on the CIS-ACE forms is:Maintained in a secure computer database and a case file. This information is used by CIS-ACE to document services provided to students and families to evaluate the ACE program. I also understand that CIS-ACE may use the information to verify CIS-ACE participants, update service information, and provide closure and follow-up information. I authorize CIS-ACE to maintain the information provided for the purposes noted above in the CIS-ACE computer database and case file. I understand that my permission is being given so that:CIS-ACE can provide and/or obtain the following information from the school, the Texas Education Agency and the local agencies specified below for evaluation purposes and in order to provide services that will help my child. These services include but are not limited to supportive guidance and counseling, tutoring, enrichment, testing, and referrals to other rmation (Current year records only) Grade reportsAttendance recordsSTAAR/TAKS (or most recent in file)Disciplinary referralsFree/Reduced lunch statusHealth related information Other:__________________________________________________RIGHTS OF CONSENTBy signing this release of information form, I acknowledge the following:I understand that the records and information released under this consent will be kept confidential to the extent permitted by law and used for the purpose indicated.I understand that this consent is voluntary and may be revoked at any time by informing CIS-ACE staff, in writing, except to the extent that agencies have already taken action in reliance of it.I understand that I can obtain a copy of any record released by this consent upon request in writing to the releasing agency, subject to any applicable copying costs and legal requirements.I understand that this consent is effective for the current school year only.I am signing as a parent of a minor child or guardian of a minor child, I understand the records released may contain references to my family or me.I understand that release of records under this form is subject to any limitations placed by federal and state law.DATE: _________________________Parent/Guardian Name (Please print): _____________________________________________________Parent/Guardian Signature: (in ink)_______________________________________________________---------------------------------------------------------------------------------------------------------------------------------Staff Signature ROI received date ................
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