The Nevada Department of Education (“NDE”) would like to collect data on activities and events taking place in classrooms, schools, and school-related programs throughout the state. The Family Educational Rights and Privacy Act (“FERPA”) requires the NDE and After-School All-Stars Las Vegas (“ASAS”) 21st Century Community Learning Centers (21st CCLC) program to obtain prior written consent from the student’s parent or guardian before releasing any personally identifiable information about a student. The information requested will be used to calculate the impact 21st CCLC has on student performance and to meet reporting requirements as a result of receiving state and federal funds.
NDE and ASAS are dedicated to establishing a community learning center designated to provide students with academic and enrichment opportunities, as well as additional activities to complement their regular academic programs. Quality programs are those that demonstrate a high daily attendance rate and engagement with family members of active participants. Programs that demonstrate these characteristics are more likely to have higher student growth, increased passage rates of local and state assessments, and students pursue post-secondary education.
I understand that this authorization is made pursuant to the FERPA set forth in 20 USC §1232g and its regulation in 34 CFR Part 99 (as amended in 2012). Furthermore, I understand that this consent is made pursuant to 34 CFR 99.30(a), which requires that (1) the parent or eligible student’s consent specify the records to be disclosed, (2) state the purpose of the disclosure, and (3) identify the party or parties to whom the disclosure may be made.
By signing this form, I grant Herr Elementary School permission to disclose to ASAS the following information. I also grant permission to ASAS to re-disclose the following information to the re-disclosure parties.
1. Records Disclosure: School Registration Information/Demographic Data, Assessment Data, Student Grades, School Day Attendance, Survey Data, Free and Reduced Lunch Status, Attendance Data Student Grades, Assessment Data, Demographic Data
2. Disclosure Parties: After-School All-Stars Las Vegas
3. 21st CCLC Re-Disclosure Parties:
a. Nevada Department of Education
b. NDE contracted statewide evaluator & local 21st CCLC site program evaluators and Data Collection System Providers
c. United States Department of Education
d. 21st Century Student Support Services
4. Purpose of Each Disclosure: Collect data to calculate the impact 21st CCLC has on student performance.
All records and information regarding services will be protected by FERPA, which governs the exchange of confidential information. The exchange of information will be limited to the authorized staff of ASAS and the re-disclosure parties. No individual student data will be released beyond that which is specified in this authorization. This authorization, to receive services from ASAS and to exchange confidential information, shall remain in effect for the period of my student’s enrollment in the ASAS program, or until rescinded in writing. I understand that this release may be revoked by me at any time with a written request dated and signed by me, except to the extent that the ASAS has already acted in reliance upon this consent. Written revocations shall be sent to:
After-School All-Stars Las Vegas, 8485 W. Sunset Road, Ste. 106, Las Vegas, NV 89113
I understand that personal records are protected by FERPA and any additional disclosure or re-disclosure, not authorized by this consent or otherwise permissible pursuant to federal or state law, is prohibited.
I have read this authorization before signing and I fully understand the contents, meaning, and impact of this release.