Hazel Park Promise Zone Registration Form

I hereby authorize any school that I am enrolled in that participates in the Promise Zone Scholarship, through its agents and employees, to release any of my financial aid, attendance, demographic and/or academic record information, in whole or in part, to my local Promise Zone Authority/Organization coordinator, or his/her designee, to facilitate the analysis of my scholarship eligibility and the subsequent educational and economic impact of this scholarship.

As a recipient of a Promise Zone educational scholarship, that award information becomes part of my educational record. By consenting to receive any scholarship amount awarded to me, I agree to allow the release of this information in my educational record to third parties specified under the Family Educational Rights and Privacy Act (FERPA). FERPA affords certain rights to students concerning the privacy of, and access to, their education records. While this form authorizes my school, in conjunction with the local Promise Zone Authority/Organization, to release educational records to third parties, it does not obligate either entity to do so. My school reserves the right to review and respond to requests for release of my educational record on a case-by-case basis. For additional information, I can visit the U.S. Department of Education’s website at www.ed.gov/policy/gen/guid/fpco/ferpa/index.html.

The Promise Zone Scholarship can have several positive impacts on postsecondary enrollment, persistence, degree attainment and overall success in college. To understand these impacts, I authorize my postsecondary academic record information, in whole or in part, to be released back to my local Promise Zone Authority/Organization coordinator, or his/her designee, in adherence to FERPA for analysis to inform and improve the Promise Zone Scholarship program.

I also authorize my local Promise Zone Authority/Organization to use information regarding my scholarship in promotion of the Promise Zone Scholarship. The Hazel Park Promise Zone, and its entities, may be authorized to use my portrait, picture, photograph, name, voice and/or image on videotape, audiotape or film, or any other reproduction of me and to distribute and/or exchange copies of these to promote the program and the public schools of Hazel Park. No compensation is offered in exchange for permission.

This release is authorized starting on the date of the electronic signature on this agreement and after scholarship receipt for statistical purposes. To rescind this Authorization, I understand that I must submit a written notification of rescission to my school. I will also notify my local Promise Zone Authority/Organization in writing of my decision to rescind my authorization. This rescission would result in the termination of my receipt of the scholarship.

My signature (or that of my parent/guardian if I am under the age of 18) electronically via date stamp indicates that I have read this Authorization to Release Educational Records form and that I authorize the release of educational records as described above.