Form KSDE/FERPA001 Appendix 5H "Consent for Release of Information" - Kansas

What Is Form KSDE/FERPA001 Appendix 5H?

This is a legal form that was released by the Kansas Department of Health & Environment - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2017;
  • The latest edition provided by the Kansas Department of Health & Environment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form KSDE/FERPA001 Appendix 5H by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

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Download Form KSDE/FERPA001 Appendix 5H "Consent for Release of Information" - Kansas

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Appendix 5H
KSDE/FERPA 001
Revised Jan 2017
Consent for Release of Information
This form authorizes the State Department of Education and any school district in which your child is
enrolled to share information about your child with each other and with the other agencies listed below that
are concerned with, or are involved in, meeting the needs of your child. You are advised that:
Information will not be shared unless it is necessary to meet the needs of your child.
Information from the Department of Education or the school may include any or all educational records
and information supplied to the Department or to the school by others, such as medical reports from
doctors and reports from other agencies including DCF, KDOC-JS, KDHE, and KanCare, that are
included in your child's educational records.
The purpose for sharing information is to provide appropriate services for your child, avoid duplicative
or unnecessary assessments or immunizations, avoid unnecessary delay in providing services while
waiting for records to be transferred, enable your child to be successfully involved in school, and to
assist the school district to receive funds from Medicaid to assist in paying for some special education
services.
This consent will remain in effect until it is revoked in writing by you.
You have the right to revoke this consent at any time.
The State Department of Education and the school district in which your child is enrolled will release
information, upon request, to the following agencies and their agents or contract service providers:
Department for Children and Families; Kansas Department of Health and Environment; Kansas Department of
Corrections Juvenile Services; KanCare; Kansas Kids @ GEAR UP.
By signing and dating this Consent for Release of Information form, you give consent to the State Department
of Education and the school district to share any or all educational records regarding your child with each
other and with the agencies listed above. Your signature also indicates that you understand that any release
of information is for the purpose of meeting your child's needs through the cooperative efforts of the agencies.
_____________________________
______________________________
Printed Name of Child
DOB
_____________________________
______________________________
Parent or Guardian Signature
Relationship
_____________________________
_______________________________
Printed Name of Parent or Guardian
Date
Appendix 5H
KSDE/FERPA 001
Revised Jan 2017
Consent for Release of Information
This form authorizes the State Department of Education and any school district in which your child is
enrolled to share information about your child with each other and with the other agencies listed below that
are concerned with, or are involved in, meeting the needs of your child. You are advised that:
Information will not be shared unless it is necessary to meet the needs of your child.
Information from the Department of Education or the school may include any or all educational records
and information supplied to the Department or to the school by others, such as medical reports from
doctors and reports from other agencies including DCF, KDOC-JS, KDHE, and KanCare, that are
included in your child's educational records.
The purpose for sharing information is to provide appropriate services for your child, avoid duplicative
or unnecessary assessments or immunizations, avoid unnecessary delay in providing services while
waiting for records to be transferred, enable your child to be successfully involved in school, and to
assist the school district to receive funds from Medicaid to assist in paying for some special education
services.
This consent will remain in effect until it is revoked in writing by you.
You have the right to revoke this consent at any time.
The State Department of Education and the school district in which your child is enrolled will release
information, upon request, to the following agencies and their agents or contract service providers:
Department for Children and Families; Kansas Department of Health and Environment; Kansas Department of
Corrections Juvenile Services; KanCare; Kansas Kids @ GEAR UP.
By signing and dating this Consent for Release of Information form, you give consent to the State Department
of Education and the school district to share any or all educational records regarding your child with each
other and with the agencies listed above. Your signature also indicates that you understand that any release
of information is for the purpose of meeting your child's needs through the cooperative efforts of the agencies.
_____________________________
______________________________
Printed Name of Child
DOB
_____________________________
______________________________
Parent or Guardian Signature
Relationship
_____________________________
_______________________________
Printed Name of Parent or Guardian
Date