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FERPA* Release Form
Federal Educational Rights Privacy Act*
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1
My Name
First Name
Last Name
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2
Phone Number
My Phone Number
Please enter a valid phone number.
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3
My School, College, Technical School, or University
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4
I Authorize My School To Speak With Orchard Human Services, Inc. Staff
I authorize my school to speak with Dr. Darleen Claire Wodzenski and other Orchard Human Services, Inc. Staff about all aspects of my school life including academic, financial, disability-related, and learning support.
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5
Date
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Date
Year
Month
Day
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6
Signature
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