Program Verification/Student Authorization for Release of Information

Submit your information if you'd like to request program verification.

The only information available after three years is as follows:

Legal name of student at time of participation in the class/program.

Entrance and departure dates of each school year.

Subjects taken during each year. (cf. 5121 - Grades/Evaluation of Student Achievement)

Once your information is received it will be reviewed and you will be contacted.

*** For DSP (Direct Support Professional) Records, please go to:

https://www.dsptrain.org/

Requests prior to 2005 cannot be processed.

First Name: *

Last Name: *

Other Last Names Used: 🛈

Mailing Address: *

Mailing Address Line 2:

City: *

State: *

ZIP: *

Primary Phone Number: *

Email Address: *

Last 4 Digits of SS#: *

Date of Birth: * +

Year of Attendance (2014-2023) *

Information to release:

Attendance

Transcripts

Program Verification - Free

CRY-ROP will provide the first 2 copies free of charge.
Each additional copy will cost $2.00.

I, therefore, request that the information listed be released to the following: * 🛈

Self

Other Other

Delivery Method *

By mail

In person

Fax Fax

Name of the Class(es): *

Additional attachments:

Additional Instructions or Comments:

Under Federal legislation, namely the Family Educational Rights and Privacy Act of 1974, I understand that my educational records cannot be released without my written permission or a Parental Affidavit of Dependency certified by my parent or guardian.

This information is released subject to the confidentiality provisions of appropriate state and federal laws and regulations which prohibit any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations.

In executing this authorization, I fully and completely release and hold harmless all present and past CRY-ROP employers and their officers, agents, assigns and employees, and all other persons and entities from liability for any damage, including, to the full extent allowed by law, liability under the State and Federal Constitutions, California Civil Code Sections 45 and 46 and California Labor Code Section 1054 or any similar laws of other states or political entities, which may result from furnishing information which I am permitting to be released by way of this authorization.

I have carefully read and understand all of the provisions of this authorization and have voluntarily and without coercion or duress agreed to and signed this authorization. I acknowledge and understand that this release is valid until I revoke this release by delivery of written notice to CRY-ROP.

Signature Required (by signing my name, I certify that I am the individual named above.) *

clear

Signed on: * +

Please allow up to 5-7 business days for processing once your authorization form has been received.

Program Verification/Student Authorization for Release of Information

Requests prior to 2005 cannot be processed.

CRY-ROP will provide the first 2 copies free of charge. Each additional copy will cost $2.00.

CRY-ROP will provide the first 2 copies free of charge.
Each additional copy will cost $2.00.