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Appendix G

UNT FERPA Consent to Release Educational Records and Information for Clinical Teachers

Note: Clinical Teacher must sign and submit this form through Qualtrics before Clinical Teacher Orientation

This release represents your written consent to permit the University of North Texas Educator Preparation Program to disclose educational records and any information contained therein to the specific individual(s) identified below.  Please read this document carefully and fill in all blanks.

  I, ______________________________________________________ [print full legal name as it appears on your driver's license] am a teacher candidate at the University of North Texas and hereby give my voluntary consent to officials:

A.  To disclose the following records:

  • Records relating to any of my field-based experiences
  • Records relating to my performance in the field
  • TExES Exam Results

B.  To the following person(s):

  • School districts or other agencies associated with field-based experiences
  • School-based/Agency-based administrators
  • School-based/Agency-based cooperating teachers/mentors
  • Program faculty and administrators

C.  These records are being released for the purpose of:

  • Conversing and reviewing performance
  • Acquiring feedback
  • Procuring required signatures

I understand that under the Family Educational Rights and Privacy Act of 1974 (“FERPA” 20 USC 123g; 34 CFR §99 (commonly known as the “Buckley Amendment”) no disclosure of my records can be made without my written consent unless otherwise provided for in legal statutes and judicial decisions.  I also understand that I may revoke this consent at any time (via written request to the educator preparation program), except to the extent that action has already been taken upon this release.  Further, without such a release, I am unable to participate in any field-based experiences including 30 clock hours of observation, Clinical Teaching, or internship. 

NOTE:  Your signature on this document is required for admission to clinical teaching. This document is located at:  https://unt.az1.qualtrics.com/jfe/form/SV_4URsdirJLHI859j