Orange County NC Website
Browse       Search
DocuSign Envelope ID: D6EB45D6-6C12-4C2B-895B-067AF17D828F <br /> manager . Signing this Agreement constitutes the granting of consent for <br /> disclosure of protected education information under the Family Educational Rights and Privacy Act <br /> (FERPA). <br /> Please complete sections A or B, as appropriate, and sign C below. <br /> A. For Parent/Guardian of child under 18 years old. <br /> Parent/Guardian First Name Parent/Guardian Last Name <br /> As the Parent/Guardian of, <br /> Print Child's Legal First Name Print Child's Legal Last Name <br /> consent to the release of personally identifiable information of the Child named above, subject to the <br /> terms of this Consent Agreement. <br /> B. For Adult 18 Years or Older or student enrolled in college (please print clearly) <br /> I, , <br /> Print First Name Print Last Name <br /> consent to the release of personally identifiable information of the Child named above, subject to the <br /> terms of this Consent Agreement. <br /> C. By signing this Consent Agreement, I agree that I have read and understood the above and consent <br /> to all of the above statements. I understand that signing this Consent Agreement is voluntary and is <br /> not a condition for receiving services from Orange County FSA.This Consent Agreement is valid for <br /> the duration of the Orange County FSA initiative. I maintain the right to discontinue this permission at <br /> any time by contacting the Orange County FSA Site Manager at <br /> Signature Date <br /> For Orange County FSA Use Only <br /> Partner collecting this consent agreement: <br /> Consent record recorded in Orange County FSA Site on (date): <br /> Orange County FSA case management number: <br /> 18 <br />