Seattle Public Schools Procedures for Community Based Organizations (CBO) ‘Accessing Student Educational Records Directions for CBOs submitting requests (All forms must be filled out in black or blue ink, or typed): 1. Complete Appendix A (CBO form ‘Agreement to Comply with the FERPA, to accurately represent the CBO's understanding of, and agreement to uphold FERPA laws. Each party signs accordingly. Incomplete forms will not be accepted. a, Access to student records is for the current school year only. b. Anew form must be completed each school year, if the organization is to continue providing services. c. Signed by District Representative ie, Principal or SPS Program Manager. Seattle Public Schools June 20132. Provide cover memo a) Memo on organization letterhead b)_ Simple statement that includes your organization name and why student data is needed, e.g. “Attached is the information regarding FERPA authorization for the Support Students’ Success project in collaboration with ABC Elementary School, Middle School, High Schoo! (list each school).” ¢)_ Name, phone and email for the person to contact if we have questions about your request. 4d) List of attachments, e.g, “Attachments include: (1) Appendix A agreement; (2) student information list; and (3) Appendix 8 (Consent to Release of Education Records).” 3. Enclose completed Appendix 8 (Source) or Automated Data Report (Parent form Consent to Release of Education Records under the FERPA Agreement ~ signed by authorized Parent or guardian a) Edit/fill in your organization's information in the yellow highlighted sections b) Provide letter for parents stating reason for submission of Appendix B and instruction for completion. CBO will obtain signed permission of the authorized parent or guardian of the consent form. d)_ Attach list of students: (1) alphabetized by students’ last name, first name, (2) Seattle Public Schools student identification number, (3) birth date, and (4) program representative's name with his/her email address. e) Organize forms in alphabetical order by student last name, first name. 4. Make copies of Appendices A & B for organization records and store in a secured file. 5. Mailin originat documents [Cover Memo, Appendices A & B, and list of students). Do not email documents. If you have questions contact Courtney Cameron, cicameron@seattleschools.org Courtney Cameron, Manager of Schoo! and Community Partnerships Seattle Public Schools | Office of School and Community Partnerships PO Box 34165 Mail Stop 33-160 Seattle, WA 98124-1165 6. Staff member assigned to students will be notified via email to confirm account login. Once login is received do not share login and password. Login and password is assigned to one user. 7. Notify Parents/Guardians why organization is requesting their students’ information, a. Letter (Sample Attached) b. Phone ©. Imperson Seattle Public Schools June 2013we i ional Righ acy Act ScHOOLS (from US Department of Education http://www.ed.gov/ policy/aen/quld/fpco/ferpa/index. html) ‘The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 12329; 34 CFR Part 99) Is a Federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. FERPA gives parents certain rights with respect to their children's education records. These rights transfer to the student when he or she reaches the age of 18 or attends a school beyond the high school level. Students to whom the rights have transferred are “eligible students. + Parents or eligible students have the right to inspect and review the student's education records maintained by the school. Schools are not required to provide copies of records unless, for reasons such as great distance, it is impossible for parents or eligible students to review the records. Schools may charge a fee for copies. + Parents or eligible students have the right to request that a school correct records which they believe to be inaccurate or misleading. If the school decides not to amend the record, the parent or eligible student then has the right to a formal hearing. After the hearing, if the school still decides not to amend the record, the parent or eligible student has the right to place a statement with the record setting forth his or her view about the contested information. + Generally, schools must have written permission from the parent or eligible student In order to release any information from a student's education record. However, FERPA allows schools to disclose those records, without consent, to the following parties or under the following conditions (34 CFR § 99.31): ‘© School officials with legitimate educational interest; Other schools to which a student is transferring; Specified officials for audit or evaluation purposes; Appropriate parties in connection with financial ald to a student; Organizations conducting certain studies for or on behalf of the school; Accrediting organizations; To comply with a judicial order or lawfully issued subpoena; Appropriate officials in cases of health and safety emergencies; and State and local authorities, within a juvenile justice system, pursuant to specific State law, Schools may disclose, without consent, “directory” information such as a student's name, address, telephone number, date and place of birth, honors and awards, and dates of attendance. However, schools must tell parents and eligible students about directory information and allow parents and eligible students a reasonable amount of time to request that the school not disclose directory information about them, Schools must notify parents and eligible students annually of their rights under FERPA, The actual means of notification (special letter, inclusion in a PTA bulletin, student handbook, or newspaper article) is left to the discretion of each school.SEATTLE ns APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and (agencylorganization name), dated Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. ‘The parties agree that (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can i only be used to perform the educational services described in their agreement with Seattle Public, Schools. (agency/organization name) agrees that any ‘educational records received fiom the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. (agency/organization) name further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: = Print Name: Title: _ Signature: 7 _ District Representative: Title: Program and Work Location: Signature: Exhibit A: Student information accessible through The SourceTHE SOURCE (Grganization/ Agency Name) 2013-2014 School Year Consent to Release of Education Records (THE SOURCE) Under the Family Education Rights and Privacy Act (FERPA) (PRINT parentiguardian name), consent wo the release of my child's education records agency. from the Seattle School District to "understand that education records include, but are not limited to Name of student School of student Attendance ‘Assignment Grades Upcoming Assignments Missing Assignments ‘Test Scores, including MSP/HSPE Scores ‘This release includes permission to agency staff ro access my child's academic records online, using The Source. {understand thatthe purpose of sharing these records with (full name of | staff member who will access student records*) is 10 keep my ahi ~ of Saine Saif member, eg. “CLCIAMlerichool Program Coordinator" *) informed of histher academic program and progress. Agency staff will work with the school, the family and the student in an effort 0 improve my child's success at school 4 acknowledge that I may submit a subsequent notification in writing directing the Seattle School Distriet to no longer release information to agency staff. ‘This Release of Information witl be valid forthe 2013-14 school year (valid two weeks after Iast day of school). Seattle School District is authorized to release information to the following agency (please print clearly) PRINT Student's Name (First and Last name) te Signed ‘Student Date of Birth PRINT Prograin stall member name and title * "4Stadent School District ID # ‘Signature oF salt member © ParentiGuardian’s Signature (i youth is 17 or younger) mail Address of staff member > Siudent’s Signature (if youth is 18 or oldery ‘gency Name **Student ID # ean be found on student ASB card, report eard, official school mailing, or by contacting wr student’s school Business Mailing Address ‘Ageney Phone Nomber June 2013" Appendix B: Parent Form[Your [Street {City, Decem Courtnt Seattle Office PO Bo: Mail Si Seattle, Dear N Please (1) Stud Educati sehool( Please I Sincere} [Your [Tite] [Email] fame} Address] sT ZIP Code} yer 12, 2012 -y Cameron Public Schools sf School and Community Partnerships 34165 p 33-160 WA 98124-1165 .. Cameron: find a copy of the following attachments, (1) Appendix A (Agreement to comply), jent information list; and (3) completed Appendix B (Consent to Release of 1 Records) forms for students enrolled in our program at [insert name of DI. me know if you need any question and/or need additional information. ys fame] Enclosures: Appendi ‘A, Student list, Appendix B (Consent Forms)John Doe ‘5 Youth Services Student List idoe@sps.net 206-555-5555 Garfield [Student | Student ‘SPS School | Birth Date | Staff Name/Email Last Name Studentio | Doe 555555___| 01/12/99 | John Doe/ jdoe@apanet Smith, 777777 {01/12/99 _| John Doe/ jdoe@sps.nethy sear fen y APPENDIX A ‘Agreement to Comply withthe Federal Eduentonal Rights and Privacy Act is This is @ mutually-agreed upon addenduun to an agreement for family involvement and student support between the Seattle School District and Ful ene Youn, ‘Community Based Organ following all school support, including tu the schoo} currently af named agency and Seat Public School staff ean disc offering services to Seatde Public School students, and and procedures for engaging students for the purposes of ilowing any education plan provided by the teachiny staff of within the agreed scope of work existing between the need to sign the following agreement before Seatlle lent egucational records to their staff _____{agency/organization name) will for District students who have been 1 school will provide a written Hi student educational recor can The parties agr hhave access to studi identified by the schoo! for the purposes. or email of students to be served. The pe ‘only be used to perform the educational servi Schools Se {§ 1232g) and that stucent educational records received frat any other person, agency, or entity without the prior written required to make such a disclosure under an applicable law or eof FuaSenice You ___(agency“organization) m destroy any student educational records obtained through the District ‘or upon request from the District. further agrees to return or the end of the Agreement ‘Organization: Fut vice Yum Print Name: “2r0e" __ Tile: Protam Monoger Signature: Dave: 121202 Title; Sn Cearowcter District Representa Program and Work Loca SCE Dale: saa? Signauure Date: 12" Exhibit A: Student information aecessible through The SourceAPPENDIX B FULL SERVICE YOUTH (rganizalion’Agency Name) Release of Information 2012-2013 School Year Consent to Release of Education Records Under the Family Education Rights and Privacy Act (FERPA) 1, Jane Doe . (PRINT parentfguardian nam), conseot tothe release of ry child's ‘education records fiom the Seatle School Distit to ul Serie Youth agency. ‘understand that education records include, but are not limited to: 1. Name of student ‘School of student Antendance Assignment Grades Upcoming Assignment, Missing Assignments as “Tesi Scores, including MSP eee as tal rane ot matt nent wl Stes eee HE ogy RT PGontanion Posen Coordinator ee ee and the student in an effort to improve my chiles suecess a 2.586h release information 10 agency staff, g This Release of laformation wil be valid fr the 2012-13 schoo yearns long a5 sia is served by the agency ‘whichever isthe lesser ime length, ce ‘Seatle School District is authorized to release information tothe following ages (pleas® prt clearly) ohn Doe rename RINT SutensNane Dae Signed 12/12/08 #5555555 Wille Seals, Academic Advisor ‘Siudene Date of Birth & School Diswiet 1D ® [PRINT Progam af mabe ame ale ™ Signa tsa nen” seals@fullsorviceyouth.n ‘dens SigarreiTyou i War Oey Eni adie oF maT wae ® Full Service Youth ‘geaey None PO Box 34165, Seattle, WA & ‘Bisines Wating Adaees é 206-252-0754 ‘Aaeney Phone NumerDear <>, Consent to Release Education Records forms from the Seattle Public Schools are attached. By signing these forms, you are granting the School District permission to share your student’s academic information with <<>. <> uses your student's information to ensure that your student is receiving the best possible services in our program, and to monitor and improve our program’s effectiveness forall students. Seattle Public Schools has two mechanisms for sharing your student's information, and two separate consent forms. These are explained below: '* The Source: The Source is the Seattle Public Schools’ web-based.¢gmmunication and collaboration tool. > uses The Source to mtbr your student’ academe program and progress. The attached form allows the <S program staff member who is working with your student to login to The Sourcing’ 2013-2014 school year. This keeps the staff member informed about your student's cuifeht schoo! attendance, homework assignments, grades, and test scores, nd helps the staff member to coniect his or her work to your student's experiences during the school day ‘+ Automated Data Report (ADR): Like The Source, the ADR helps <> design programming to meet your student's academic needs. By looking at your student’s progress over time, we can better understand how our program activities affect their success in school. ‘The attached form allows >’s program administrator to receive an. automated report showing your student's enrollment, performance, attendance, and discipline history alongside that of other students in <>'s program: Seattle Public Schools and > take your student's privacy very seriously. Your, student's information will not be shared with anyone other than those named on the attached consent forms, and will be destroyed by > after one year. We thank you for partnering with Seattle Public Schools and <> to support your student’s success.APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and c agency dated Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staf. The parties agree that _ Co 2ae ACCESS Nos (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools ¢ agrees that any educational records received from the District are considered confidential student information protected by federal !aw, the Family Educational Rights and Privacy Act (‘FERPA’) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to. any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Lol 8 further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: _Collone Acer ese Now Print Name:_Anlren wong. Title: Prcara.m Supervisor 7 Date:__ 4/34 /(a- Signature: District Representative: om Title: Pre rel Program and Work Location velT AegaSchea Date: $a TE Signature: ZB Date: _ $ f////o_ Exhibit ‘Student information accessible through The Source July 2012APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act, This is a mutually agreed upon addendum to an agreement for family involvement and Student support between the Seattle School District and _Collexe Access Now agency dated 7 U/ 2i/ ja Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that__Colleas Achess (agency/organization name) will have access to studeht educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Col Ss O agrees that any educational records received from tHe District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA”) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Colt ga further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Callvae Access New Print Name: ArvAtea Won Title: Progen $ 1S “ Preqyien Su pecuisn - SH) Signature: bry Date: _ilf do/ (2 District Representative: Ruth MedsKer Title: Principal Program and Werk Location: West Seats Higln Schneo |_ bate: 19) (21 ‘Signature: Date: Exhibit A: ‘Student information accessible through The Source July 2012 Seattle School= College Access Now C j P.O. Box 22999 2 i ~ Seattle, WA 98122, Cour Access Now www collegeaccessnow.org, December 3, 2012 Office of School and Community Partnerships Seaitle Public Schools ‘Mail Stop 32-195 ‘To whom it may coneern: Attached please find paperwork for FERPA authorization for College Access Now at Chief Sealth International High School. College Access Now stail’ need access to The Source in order to monitor the academic progress of program participants, For any questions regarding this request, please contact me. ‘Thank you, Katie Panhorst Program Supervisor katie@collegeaccessnow.org Klpanhorst@seattleschools.org 206-400-6886 x107 Ene: ~Appendix A -List of students, caseload of Nora Furstenberg-Carroll ~Appendix B forms, caseload of Nora Furstenberg-Carroll - List of students, caseload of Sarijana Clark ~Appendix B forms, caseload of Sarijana Clark Predicate to making college admission possible for ttented, motivated and economically dvuunuaged sndomsCollege Access Now Memo Source Support Bill Kautz, Program Supervisor-Franklin High School, College Access Now Dr. Jennifer Wiley, Principal, Franklin High School 11162012 Releasing Student Records on The Source to Community Based Organizations (CB0's) The Source Access Qilached is the information regarding FERPA authorization for College Access Now at Franklin High School. College Access Now is currently operating in 6 high schools in the Seattle School District and will have. Served over 500 students through the junior and senior programs through their 8 years of operation Ninety-seven percent of students are the fst in ther famiies to attend college and all students qualty 2s lowrincome, Ninety-nine percent of CAN students completed a FAFSA and were accepted to at least one college, and ninety-one percent enrolled in a postsecondary program, This year the College Access Now program at Franklin High School has expanded to serve 120 Seniors and 60 juniors. In order to ensure our success as a program and maintain our high success rate of students being accepted to college who have gone through our program, itis imperative that we have access to The Source. This will alow us to monitor our student's academic progress and attendance along with providing the information we need to collaborate with teachers to ensure thelr ‘success at Franklin High School and their success in a postsecondary program, ‘We greatly appreciate your effort in providing us access for the sludents attached in this document. Kind Regards, Bill Kautz Program Supervisor-Franklin High Schoo! College Access Now 206.400.6886 ext. 105, bbil@collegeaccessnow.org Atachments Included: Appendix A Agreement; student information list individual parent authorization forms;eee MEMORANDUM eS 7 COURINEY CAMERON, OFFICE OF SCHOOL AND COMMUNITY PARTNERSHIPS ANDREA WONG, PROGRAM SUPERVISOR-WEST SEATILE HIGH SCHOOL, COLLEGE, ACCESS NOW SOURCE ACCESS DECEMBER 11,2012 RUTH MEDSKER, PRINIPAL, WEST SEATTLE HIGH SCHOOL Please find attached information regarding FERPA authorization for College Access Now in collaboration with West Seatle High School College Access Now is curzently operating in six high schools in the Seattle Public School District and will have served over 500 students through the junior and senior programs through theis eight years of operations. 97% of students are the frst in thei families to attend college and all students qualify as low-income, 99% enrolled in « postsecondary program. ‘This year the College Access Now Program at West Seattle High School is serving 30 juniors and 35 seniors. In order to ensure our success a8 a program and maintain our high success rate or students being accepted to college, its imperative that we have access to The Source. This will allow us to ‘monitor our student's academic progress and attendance along with providing the information we need to collaborate with teachers to ensure their success at West Seattle High School and their success in a postsecondary program, We greatly appreciate your effort in providing us access forthe students attached in this document, Sincerely, Andrea Wong Program Supervisor, West Seattle High School College Access Now (206) 400.6886, Exe. 110 Appendix A, Agreement to Comply with FERPA Student List Appendi B, Release of Information FormAPPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and __ Communities In Schools of Seattle, agency dated _ 9/2 Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that _Communities In Schools of Seattle__(ageney/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. ___ Communities In Schools of Seattle__agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. § 12329) and that ‘student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Communities In Schools of Seattle__ further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Communities In Schools of Seattle Print Name: ___Beth Graves Title: _School Success Coordinator. Signature: Pat i 2d Maarr~oo Date: 9/ AS//2 District Representative: __Sahnica Washington___Title:__ Principal Program and Work Location: Roxhill Elementary Date: Signature: = Date: Yt] vz. Exhibit A: Student information accessible through The Source ) Ye BA) IW 15 July 2012 \u& Bohocaure PH: 206.252.0008 te Communities In Schools Seattle Memo: Attached is the information regarding FERPA authorization for students referred to Communities In Schools of Seattle at Roxhill Elementary. CBO site contact information: Beth Graves- School Success Coordinator 206-252-9580 rave leschools. For questions regarding the submitted forms please contact the person listed above.Attachment # 8 APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Asian Counseling and Referral Service (ACRS) dated July 5, 2012. Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of Support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff, The parties agree that Asian Counseling and Referral Service (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Asian Counseling and Referral Service agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Asian Counseling and Referral Service further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Asian Counseling and Referral Service Print Name: Diane Narasaki Title: Executive Director Signature: es i Date: 1] |aow : ¢ cecluey Camere Title: Bog Sci + Cau Du fuoslip s SSCEE Date: Program and Work Location: Signature: oN Ge Cate, 287 LE Exhibit Student information accessible through The Source District RepresentativAPPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and_Biozina Tra’ Child Care agency dated 10 7Zo/ia 5 Community Based Organizations offering services to Seattle Public School students, and following alll schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that_Blazt 9 Traile Child Core (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that ‘such student educational records can only be used to perform the educational services described in thejr agreement with Seattle Public Schools. Zid “Thal chs Caye_ agrees that any educational records received from the Distfict are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (‘FERPA’) (20 U.S.C. § 12329) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Haz ins : Pole Child ore further agrees to return or destroy any student educational#ecords obtained through the District at the end of the Agreement or upon request from the District. Organization: Blazin Trak child Core Print Name: a Garrg Title:_“Direchoe 0 Signature: Date: (Uf 40,12 District Representative: David Dockendor’ Title: Principal Program and Worf Locatio, aber K-8 Sehool_ date: ‘Signature: Date: _/Q-3o0-/2 Exhibit A: Student information accessible through The Source “ husOur mission is to... ~..provide staff and families a safe, diverse childcare environment dedicated to respectful communication, problem solving, creative learning and the freedom to play! CHILDCARE Hello Ms. Cameron, Here is our first set of FERPA authorization forms for the SEAT Pilot Project through which Blazing Tails partners with Pathfinder School to enhance the academic success of the kids we serve, We hope to gather five or ten more forms in the next few weeks, If you have questions you may contact Rita Garton, or Dena Baldwin at 206-937-5160 or Email: titagarton@blazinatrails.ora, or denabaldwin@blazingtrails.org. Attachments : Appendix A Alpha list of students Parent Release of Information forms Thanks for your time,. Blazing Trails Childcare — Pathfinder PTSA’s non-profit childcare ‘5012 SW. Genesee Street Seattie, WA9BL16 USA Phone: (206) 933-5383 Fax: (206) 252-9711 Email: blazingtrals@blazingtrais.org Website: http://unw.blazingtralls.orgAPPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and _Chiove Swtuvnantan 2 Secs Conten (Ci1se) agency dated oct. 2 aia. Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that cise (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Cis¢ agrees that any educational records received from the District are considered confidential student information protected by federal aw, the Family Educational Rights and Privacy Act ("FERPA") (20 U.S.C. § 12329) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. ise further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: _Chvoar 9fyecadao X Seevin Comte CCESE) Print Name: Uo che Title: _Closica® Directo Signature: Date: _\*/ (i> Kmerer Title: Sclrt Cum Patrerslirr District Representative: Program and Work Location: DSCEL Date: Signature: _Z q {Cx Date:_£ /0-67e Exhibit A: ‘Student information accessible through The Source August 2011APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle Schoo! District and Community Day School Association, dated September 5, 2012. Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sigh the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Community Day School Association will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Community Day School Association agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (‘FERPA’) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Community Day School Association further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District, Organization: choot ASsociahin CCPSA Print Name: _Nicole 0. ey Title:_ Center Directo Signature: Date: _ 9/18/12 District Representative: zit. Ayvamale: Title:__PAx incey Pad Program and Work Location: Date: 4. jx -) 2 — Signature: 7 Date: _ 9/5 «pe Exhibit A: ‘Student information accessible through The Source August 2011APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and ‘student support between the Seattle School District and__ <0 52) Hawthorn agency dated Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the schoo! currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that_C 041) y (agencylorganization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools, 2 D Hudinres agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA") (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make Such @ disclosure under an applicable law or cout order. Dole 1 He a further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Print Name: ‘Signature: Signature: Date: _/4-/2-7e Exhibit A: ‘Student information accessible through The Source ,APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Community Day School Association, dated May 4, 2011. Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Community Day School Association will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Community Day School Association agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (*FERPA’) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Community Day School Association further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Joan tind A ngoroot, Date:_4/ 20|a46 1o~ District Representative BO) OS\Ron~ Title: Paice Program and Work Loy Aland mek lem. pate: 3136] 40)2- Signature: Date: 7-4 T2 Exhibit Student information accessible through The Source Organization: Print Name:APPENDIX A ‘Agreement to Comply with the Federal EdGational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Community Day School Association, dated Maya,20iT & IZ Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Community Day School Association will have access to. student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Community Day School Association agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (FERPA’) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Community Day School Association further agrees to retum or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Print Name: Signature: Signature: Exhibit A: ‘Student information accessible through The SourceAPPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and ‘student support between the Seattle School District and Community Day School Association, dated September 5, 2012. Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Community Day School Association will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Community Day School Association agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA") (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Community Day School Association further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: __Community Day School Assoc. at Leschi Elementary, Print Name: Kris Baldassj Title: Center Director. Signature: Date: $40 /2__ District Representative: Coshe ner Title: Principal Program and Work Logatioi Eire Date: 7 2O-[ 2 Signature: Date Exhibit A: Student information accessible through The Source August 2011APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Community Day School Association, dated September 19, 2012 Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Community Day School Association will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Community Day School Association agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA") (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Community Day School Association further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization; Print Name: Signature: District Representative: Program and Work Loss Signature: Exhibit A: ‘Student information accessible through The SourceAPPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family it student support between the Seattle School District and Community Day Schad] ‘ASsdelatiol agency dated October 17, 2012. ‘Community Based Organizations offering services to Seattle Public Schoo! students, and following all schoo! district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. Sif (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the en are 5H] agrees that any educational records received fror ed confidential student information protected by federal law, the Family Educational Rights and Privacy Act (‘FERPA’) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless Tequired to make such a disclosure under an applicable law or court order. Community Day School Associatio further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District Organization; COMMUNITY Davy Scho! Associa fan Print Name: Melinda i Title: Contey Director Date: 10.17 05 Signature: Exhibit A: Student information accessible through The Source July 2012APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Wet Schoo! hoo (CDSAY agency dated 10 (5 [1 Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that_CTS (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served, The parties agree that ‘such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA") (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Communi hy Dis Sdvoat Assn abea Print Name: Sonniter Couper Title: Center Diectar Signature: >) Signature: Exhibit A: ‘Student information accessible through The Source July 2012APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Community Day School Association, dated May 4,2044- 4. 72,.(2_ Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Community Day School Association will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Community Day School Association agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Community Day School Association further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Comonurty Day Scinoo\ ASSeciot ion® Sanisio Print Name: Ay my COP Title: Center Dicector Signature: _A) Date: 1-Q)2- | District Representative: Title: 01 Mos nef Program and Work Loc mM Si Date: "7/2. Le Signature: a 5 Cara Date:_2 2. ZL 2 Exhibit A: ‘Student information accessible through The SourceAPPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and ident Support between the Seattle School District and ee agency dated _41 Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The partis agree that Commun foe Yount (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational ices described in their agreement with Seattle Public Schools. Command agrees that any educational records received {rom the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (‘FERPA’) (20 U.S.C. § 12329) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, less required to make such a disclosure under an applicable law or court order. ary foi further agrees to retum or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization et Yor Print Name: ies 7 Title: Proagam Apministeeoe Signature: , Date: _4|20|12. District Representative: VJ\\se@ Seals ite: FSCS Grant Coordinator jon: SHOAL Commuanitry PAEMELMIPS Date 12] 3] 2012. Date: _12. wee Vv A Ons ‘Student information accessible through The Source [ i ( Program and Work, Signature: Exhibit A:Append ~ A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and [East African Community Services], dated [9/12/2012]. Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the schoo! currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that [East African Community Services] will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. [East African Community Services] agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (‘FERPA’) (20 U.S.C. § 1232g) and that student educational records received from the @ District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. [East African Community Services] further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District, Organization: Eos ACrican Commun: Services Print Name: Foiso\ Soma Title:_Proqrom Oice chor Signature: FEE Date: _@ h2/ 2012 District Representative: __/ a ¢/ Ga Title: Moy. Sebel + Chg Panloess Program and Work Location: (JISC EE ae d 12 Signature: Bae Bo Co ——— Date: 7 “0/12 Coaren Ta wer Exhibit A: ‘Student information accessible through The Source Foisal Joma: Farsal Oesstabncancs.orgAPPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle Schoo! District and El Centro de la Raza agency dated __9/24/2012 Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that El Centro de la Raza {agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools, El Centro de la Raza agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA") (20 U.S.C. § 12329) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law ot court order, El Centro de la Raza further agrees to retum or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District, Organization: __El Centro de la Raza Print Name: __ Cristina Jimenez __Title: Youth Employment Program Coordinator Signature: ino i Date: 9/24/2012 District Representative: Jueg Cau Title: _clwa/ + Gut. Panbesbyps Program and Work Logation; SCEE Date:_727-/2 Signature: : Date: Exhibit A: Student information accessible through The Source July 2012The Center for People of All Races ‘Avoice and a hub for the Latino community as we advocate on behalf of our people and work to achieve socal justice. Programs & Services September 25, 2012 With over 24,000 volunteer hours, ElCentro dela Raza serves 22,884 individuals and 0,673 families annually through the following Amiga Courtney Cameron, programs and services Luis Alfonso Velésques Flores As promised my program's originals that were emailed to you on “After School Program Basic Healthcare Enrollment 9/24/12 Café con El Centro College Readiness Enclosed are: Crisis Advocacy 1- Appendix A ECR Transitional Housing 15 - FERPAs (Appendix B). El Patio Apartments ESL & Citizenship Classes Eviction Prevention Financial Literacy Food Bank Respecttully, Foredonure Prevention 1 Homeless Assistance Program Quich ho d Homeownership Program aerate Hope for Youth Footy Civil | Program Coordinator Rights History Classes Bebes-Infant Mortality Prevention ‘José Marti Child Development Center Juvenile Justice Policy/Advocacy Parent Involvement & Education Latino Hot Meal Program ‘Youth Violence Prevention ‘Senior Nutrition & Wellness Senior Home Delivered Meals ‘Veteran's Services ‘Legal Clinie Site ‘Tax Preparation Site Local, State, National & International Coalition Building Immigrant/Human/Civil Rights Social Justice Advocacy Cultural/Political/Social Events Community Service Site Service Learning Site Community Meeting Space Community Action Agency - United Way Agency - Affiliate of National Council of La Raza 2524 16% Avenue South, Seattle, WA 98144 - (206) 329-0442 tel - (206) 329-0786 fax ‘wiww.cleentrodelaraza.org 501(c)3 Nonprofit Tax ID: 91-0899927APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and __ agency dated Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records, to their staff. The parties agree that (agencylorganization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools, agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA") (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District Organization Greve Health Cecperstive Print Name: Kedhie Wuvebacher Tite Manager, Adelos cat Services Signature: a. Wuylow bw Date: _12|'4/2012 District Representative: Title Program and Work Location: Date Signature: _____ Date:APPENDIX A. Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and International Community Health Services (ICHS) dated 12/18/12 Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the purposes Of support, Including tutoring, and following any education plan provided by the teaching staff of the schoo! currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff The parties agree that ICHS will have access to student educational records (Exhibit A) for District students who have been identified by the schoo! for the purposes of this program ‘The schoo! will provide a writen list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools, ICHS agrees that any educational records received from the District are considered Confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA’) (20 U.S.C. § 12329) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. ICHS further agrees to retum or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: international Community Health Services Print Name: Sherry! Grey Title: Program Supervisor Signature: Sy, G go _ Date: 12/18/12 District Representative: © Title: Program and Work Location: Date: Signature: Date:12/17/2012 15:97 Fax o02/009,9 APPENDIX A ‘Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and ‘student support between the Seattle School District and _Neighborcare. Health, _agency dated _{ X//7/2or2 Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching Staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff, ‘The parties agree that _Neighborcare Health {agencylorganization name) will have access to studeni educational records (Exhibit A) for District students who have been identified by the schoo! for the purposes of this program, The school will provide a written list or email of students to be served. The parties agree that such student educational fecords can only be used to perform the educational services described in their agreement with Seattle Public Schools. __Neighboreare Health agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (FERPA") (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable lav er court order. __\Neighborcare Health___ further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District Organization: _Neighboreare Health, eee Print Name: __Colin Walker Title: School-based Program Manager ‘Signature: = Date: {2/1 2/ia District Representative Title _ Program and Work Location Date: Signature: Date| APPENDIX A ‘Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student si rer tween the Seattle School District and @ ageney di if pz Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that_|Cids |we. (agencylorganization name) will have access to student educational records (Exhibit A) for District students, who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. agrees that any educational records received rom the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA") (20 U.S.C. § 12329) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. aaa ds At. i A W Chester’ Title: Date: __|1 z District Representative: ve May A —— Title: _p rincipal Program and Work Location: West Woed land Date:_// 19/12 Signature: Zales Pwen.022_— Date:_// 2/1 Exhibit A: . —/ | ‘Student information accessible through The Source } 0 NAN ytAPPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is @ mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and - agency dated | JB] 2 Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public Schoo! staff can disclose any student educational records to their staff The parties agree that _ NELLA ___ (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The schoo! will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services dascribed in their agreement with Seattle Public Schools. _ _ agrees that any educational records received {rom the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA") (20 U S.C. § 12329) and that student educational records received fram the District will nat be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. tL further agrees to retum or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District Organization, _ —_Tite:_M. anager Signature: te (gfe Distt Reprosenttive: Ue Seals Dre Fes Grant Gonhcaher Program and Work Location: FSCS /JSCEE Ghicle 3318 date “/13/]20 12. Print Name: Signature’ Exhibit A: Student information accessible through The SourceAPPENDIX A ‘Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Odessa Brown Children's agency dated October 18, 2012, Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Odessa Brown Children's Clinic (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a writen list or email of students to be served. The parties agree that such ‘student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools, Odessa Brown Children’s Clinic agrees that any educational records received from the District are considered Confidential student information protected by federal law, the Family Educational Rights and Privacy Act (‘FERPA’) (20 U.S.C. § 12329) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Odessa Brown Children's Cl further agrees to retum or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District, Organization: DOESSA BROWN CH coGer/S CLiWie Print Name: SYcAxl RAE Te Title:__ApZECTUR ‘Signature: Date:_ /2//7/7 2 yi District Representative: Kelly Aramaki. Title: Principal Program and Work Location: Odessa Brown Children's Clinic Health Initiative at Beacon Hill International School Date: October 18, 2012 0) Signature: fea Ché&wol—-. Date: October 18, 2012 K 7 wy Exhibit A: ys \' Student information accessible through The Source July 2012Date: October 19, 2012 From: Kelly Aramaki, Principal Re: Release of Information (Appendix A) between Beacon Hill International School (BHIS) and Odessa Brown Children’s Clinic (OBC) Attached is the information regarding FERPA authorization for Odessa Brown Children’s Clinic personnel who are located on-site at Beacon Hill International School. Odessa Brown Children’s Clinic Services are outlined as follows for BHI Each school will identify students in need of services (i.e. focus students). We will review the proportion of focus students: offered service, consenting to services, and receiving ‘medical, dental and / or mental health services. Parents will need to consent to the school sharing academic and attendance data in order for accurate assessment of performance and outcomes. Both schoo! principals (Beacon Kill International School and Madrona K-8) have committed to getting parental consent and do not see this as a barrier. Once a month, the school principal, school nurse, OBCC mental health therapist, OBC nurse practitioner, school counselor and school family support worker will meet to discuss academic progress of particular focus students whom OBC is serving. Mental Health Providers will use attendance and academic data (under signed parental consent) each week for each individual student they see to help inform their care and intervention. Mental health providers will receive this information from the school secretary. Attachment: Appendix A, Please note: The student information list and individual Appendix B forms will be sent at a later date. Contact Information for BHIS: Kelly Aramaki, Principal kearamaki@seattleschools.org 206.252.2705 Contact Information for OBC: Sarah Rafton, Executive Director Sarah.rafton@seattleschildrens.org. 206.987.7200APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Open Doors for Multicultural Families agency dated May 16, 2012 Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sig the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Open Doors for Multicultural Families (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will Provide a written list or email of students to be served. The parties agree that such Student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools, Open Doors for Multicultural Families agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA") (20 U.S.C. § 12329) and that student educational records received from the District will not be disclosed to any other Person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order Open Doors for Multicultural Families further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. date: 2 27. 2 ©) GutereAine UATE Program and Wark Location pT Cul Luk Date: 6. 2/-/2- Signature: CH Date //-/-/2 - Exhi ‘Student information accessible through The SourceAgreemont to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle Schoo! District and Powerful Schools, dated Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the schoo! currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public Schoo! staff can disclose any student educational records to their staf. The parties acre that Powerful Sch2o!s will have access to student educational records (xxhibit A) for District students who have been identified by the school for the Purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Powerful Schools agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA") (20 U.S.C. § 1232g) and that Student educational records received from the District will not be disclosed to any other Person, agency, or entity without the prior written consent of the District, unless required fo make such a disclosure under an applicable law or court order. Powerful Schools further agrees to retum or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District Organization: Powerful Schools Organization Representative: Jeannie Collins-Brandon' Title: Education Director Signature: ome lots 9 — Date: _/=/-(2—_ District Representative: Winifred Todd Program and Work Yocation: Powerful Schools Reading Tutoring, Dunlap School W well Jar ate: / [4 [ip \cipa! Signature: Exhibit A: Student test scores (including MAP and MSP), attendance recordsAgreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Powerful Schools, dated Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staf. The parties agree that P: will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Powerful Schools agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA") (20 U.S.C. § 12329) and that student educational records received from the District will not be disclosed to any other Person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Powerful Schools further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District Organization: Powerful Schools Organization Representative: Jeannie Collins-Brandon Title: Education Director Signature: Date: _/I=/-/2— District Representative: Stanley Jaskot Title: Principal Program and WorlyLocation: Powerful Schools Reading Tutoring, Northgate School Signature: Date: //-6-/}- Exhibit A: Student test scores (including MAP and MSP), attendance recordsAgreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and a Support between the Seattle School District and Powerful Schools, dated Le . Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agenoy and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Powerful Schools will have access to student-educational records (Exhibit A) for District students who have been identified by the school for the Purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Powerful Schools agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (‘FERPA’) (20 U.S.C. § 12329) and that student educational records received from the District will not be disclosed to any other Person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Powerful Schools further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Powerful Schools Organization Representative: Jeannie Collins-Brandon Title : Education Director Signature: > Date: _/i-/= /2_ District Representative: Sandra Scott Title: Principal Program and Work Location: Powerful Schools Reading Tutoring and After School Program, Hawthorne School w/e Signature: a Date: //-¢~/ Exhibit A: Student test scores (including MAP and MSP), attendance recordsAgreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Powerful Schools, dated 9-S= , Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Powerful Schools will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Powerful Schools agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA") (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Powerful Schools further agrees to retum or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Powerful Schools Organization Representative: Jeannie Collins-Brandon Title: Education Director Signature: Obes ples B42 Date: __|!-/-)3— District Representative: Awnie Thompson Title: Principal Program and Work Location: Powerful Schools Reading Tutoring, John Muir School \ Signature. Qe Aascnon gst Date: U\ S| \2— Exhibit A: Student test scores (including MAP and MSP), attendance recordsAgreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Powerful Schools, dated —/a-3-pe Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Powerful Schools will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Powerful Schools agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA") (20 U.S.C. § 12329) and that student educational records received from the District will not be disclosed to any other person, agenoy, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Powerful Schools, further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Powerful Schools Organizatior Organization Representative: Jeannie Collins-Brandon Title: Education Director Signature: A y Date:_/243] (3 District Representative: Keisha Scarlett Titl Principal Program and Woy’ Location: Powerful Schools Reading Tutoring, South Shore K-8 Date: BY/2— Exhibit A: Student test scores (including MAP and MSP), attendance recordsAgreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Powerful Schools, dated 9-S=) : Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Powerful Schools will have access te student educational records (Exhibit A) for District students who have been identified by the school for the Purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Powerful Schools agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (‘FERPA’) (20 U.S.C. § 12329) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Powerful Schools further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Powerful Schools Organization Representative: Jeannie Collins-Brandon Title: Education Director ‘Signature: a tl Wibod. = Date: __/-1-/2— District Representative: Concie Pedroza Title: Principal Powerful Schools Reading Tutoring, Orca K-8 Date: //-/ 72 Program and Work Location: fe Signature: Exhibit A: Student test scores (including MAP and MSP), attendance recordsoe Powerful Schools inspiring minds creating eppertanitics December 10, 2012 Courtney Cameron Office of School & Community Partnerships Seattle School District Dear Courtney, Powerful Schools revised the FERPA permission form we used last year, per your office's request, to keep alll student and parent information laid out in the same way/in the same spaces as the original district document to aid your staff in extracting information. As you might guess, securing these permissions took sending home multiple copies for some families, often calling parents to answer questions and urge them to complete it. In this process, a few of last year’s forms were mistakenly sent home—which has the student and parent information in slightly different places on the page. These forms are flagged to make it easier for your staff to retrieve the information. Thank you for understanding, and please know we'll take steps to not repeat this mistake next year. Please call me if you have any questions: 206-722-5543 ext. 108, ‘Many Thanks, oye (304; bf. fe Collins-Brandon Education Director, Powerful Schools ELL Ave, South, Suite C © Seattle, WA 98144 office: 206/722-5543. fax: 206/760-1723 ea catint cyAPPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Public Health — Seattle & King County dated 12/3/12, Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following \ agreement before Seattle Public Schoo! staff can disclose any student educational records to their staff. The parties agree that Public Health — Seattle & King County will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students tobe served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Public Health — Seattle & King County agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (‘FERPA’) (20 U.S.C. § 1232g) and thal student educational records received from the District will not be disclosed to any other Person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Public Health — Seattle & | King County further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Public Health ~ Seattle & King County Print Name: Jessica Knaster Wasse Title: Program Manager, Community & School-Based Partnerships // Signature: “2-1 Ze Wit, ate; 19/3 // ) District Representative: Caer) (awerrA site: Myc. Sclerl + Cur Pa beled Program and Work Location: —§ JSCE E _ Date: (2 4-/2 Signature: é ea Date: /2°4-/2, Exhibit A: Student information accessible through The SourceAPPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to the Agreement for family involvement and student support between the Seattle School District and Seattle Goodwill Youth Year- Round Program dated Noerpes 13 2047 Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes Of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Seattle Goodwill Youth Year- Round Program will have access to student educational records (Exhibit A) for District students who have been identified by the School for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Seattle Goodwill Youth Year-Round Program agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA") (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Seattle Goodwill Youth Year-Round Program further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Name: Rdoeck Ws Jones Date: November 13! 2612 Title: Nout Progca m Cota snabor Organization: Seakte Gendiss District Representative: _( eo a Date: Ml 3-/2 Title: Ay Sched + Git Pa. isles Exhibit A: ‘Student information accessible through The Source Jonuary 2011APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and demic Akirver: agency dated Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff, The parties agree that “Tiny “Io femic -s_ (agencylorganization name) will have access to stddent ¢ducational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Zh ic_dcbievers __ agrees that any educational records received fron the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (‘FERPA’) (20 U.S.C. § 12329) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, ich a disclosure under an applicable law or court order. unless required to make su fay Lets | deidemic ALlievecs further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Title: _P2o ect Conrdinatye Date: _/2// Organization: Print Name: Signature: Program and Work Location: Date: Signature: Date:_ /27€/2 Exhibit A: Student information accessible through The SourceAPPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Zin. yy) “mie. CLES. agency dated /2’7/ Za, Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Zay Ze Leadeoie Achievers (agency/organization name) will have access to- Program and WorlKok Signature: Exhibit A: Student inLAKESIDE 14050 1st Avenue NE Seat, WA 34125-3099 Tel: 206-368-3600 Fae 206-368-9538, \wmakasideschook arg June 28, 2017 Courtney Cameron Seattle Public Schools Office of School and Community Partnerships PO Box 34165 Mail Stop 33-160 Seattle, WA 98124-1165 Dear Ms. Cameron: Please find a copy of the following attachments, (1) Appendix A (Agreement to comply), (1) Student information list; and (3) completed Appendix B (Consent to Release of Education Records) forms for students enrolled in LEEP (Lakeside Educational Enrichment Program) at Lakeside School. Please let me know if you need any question and/or need additional information, Sincerely, anier ftasih Li LEEP Director Latasia.lanien@lakesideschool.org Enclosures: Appendix A, Student list, Appendix B (Consent Forms)4° GRE APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and LEP (Lakeske Edvealonal Enichment Program) (agency/organization name), dated June 26,2013 Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of ‘support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. ‘The parties agree that LEEP (Lakeside EdveatonalEnrkhment Program) (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. LEP (Lakeside Educational Enrichment Program) __(agency/organization name) agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (*FERPA”) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. LEEP (Lakeside Educatonal EnichmentProgram)__(agency/organization) name further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement of upon request from the District. Organization: LEEP (Lakeside Educational Enrichment ProgramGina Rail PO Box 31209 Seattle WA 98103 ‘September 10, 2013 Courtney Cameron Seattle Public Schools Office of School and Community Partnerships PO Box 34165 Mail Stop 33-160 Seattle WA 98124-1165 Dear Ms. Cameron: Please find a copy of the following attachments, (1) Appendix A (Agreement to comply), (2) Student information list; and (3) completed Appendix B (Consent to Release of Education Records) forms for students enrolled in our program at Bailey Gatzert Elementary School, John Hay Elementary School, Whitman Middle School, and Washington Middle School. Please let me know if you have any questions and/or need additional information. Sincerely, e 5 Children's Advocate ginar@solid-ground.org Gina Rail Enclosures: Appendix A, Student list, Appendix BAPPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student support between the Seatle School District and Bf OOAWi€ LL.) Lime vGene acy she Shelter + (agencyforganization name), dated_4e Dryer Transitional — Housi Community Based Organizations offering services to Seattle Public School students, and yy! following all school district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. i in ‘The pate age that hele TIME OY an i | have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational face described in their agreement with Seattle Public Schools. Hpusin BO odview Svle+ Transit Nagency/orkanization name) agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. { § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless feud to make sucha disclosure wer an pliable lw or court order. Bt OO.AVi ew. She Het + 1ansitiona | |_Heusinfagencyorgaization) name further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. (oad yjti ste ter Transitional i | tittle CH id oo cate. | Date: 4 /1O, | CA FF1e Slo +n. Perboerclinp SCEE Date: | Caunernn Date —t.20- 15 1S | Exhibit A: Student information accessible through The Source Organization: Print Namey Signature District Representative: Program and Work Locatt ‘Signature: oura ie APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Zeno (agency/organization name), dated August 8th, 2013 Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of Support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff The parties agree that Zeno (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Zeno ___ (agency/organization name) agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Zono (agency/organization) name further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Zeno Title: Executive Director Date: August 8, 2013 District Representative: [Nvthe Seats Tite: Grant Covrds ws Program and Work Poratipn: _ \SCEC Date:_9/26//3 Signature: Date: 9/ 2] 13 eile ough Te Soc: Exhibit A: Student informath powered Formerly Explorations in Math ‘August 8", 2013 To: SPS Office of School and Community Partnership FR: Zeno/Tammie Schacher, Executive Director @ RE: Accessing student data ‘Attached is the information regarding FERPA authorization for the Zeno, a non-profit organization that Partners with elementary schools to provide math programming for students, teachers and families. Because our partners vary from year to year, we have not yet identified a specific school or set of students to collect data. As we re-connect with old partner schools and identify new partners we will ‘ask their permission to track their students participating in Zeno’s math club and students whose teacher receives math coaching from a Zeno teacher. Last year Zeno successfully collected data from Dearborn Park Elementary students on The SOURCE who participated in Zeno math club programming. The data revealed these Zeno-dosed students increased their MAP scores at a higher percentage than non-Zeno dosed students from Fall to Spring. This was the first time we had access to student data. This information is integral to our organizations future growth and development. We would like permission to identify several schools this year willing to share student data for a similar data comparison, © Please find attached Appendix A, Please contact Zeno’s Program Director, Jennifer Gaer- jenniferga@zenomth.org regarding this process or if you have further questions regarding this memo.a aes APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and_Group Hesth-Schoo! Based Health Cetars (ageney/organization name), dated e2aota ‘Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. “The parties agree that Group Hosth-School sed Hesih Carters (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. ‘Group Health School Based Hash Cerera (agency/organization name) agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. ‘Group Healt-Schel Based Heath Carrs (agency/organization) name further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement Cor upon request from the District, Organization: Goup Heatt-Sehoo! Based Heath Certs Print Name: Katie Wurbactyy. MEd, LHC Title: Manager, Adolecent Services Date: 9282013, Signature: District Representative: ats Comdinnkor Program and Work Signature:ie ae APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Ilamatonal Community Heath Senvene (agency/organization name), dated Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of suppor, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff The parties agree that Iomational Conmunity Hoath Serdces (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served, The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. _International Community Health Services (agency/organization name) agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 US.C, § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unlese required to make such a disclosure under an applicable law or court order. sierateel Communty Heath Seviess_(agency/organization) name further agrees to return or destroy any student educational records obtained through the District atthe end of the Agreement ‘or upon request from the District. Organization: Inratonal Conmuniy Heth Servicos Print Name: Tota eatayoa : ae Signature: Yoontrgy te Date, 2/6/77: District Representative: Program and Work Location: Clow | Lemay Dee Date:_4 4} 2015 Signature: Date | 4 rocarel TORS APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Nottborcare Heath (agency/organization name), dated August 14, 2013 ‘Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Nelghtorare Heath ency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list ‘or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. (agency/organization name) agrees that any ict are considered confidential student information Protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. [Nelghborcare Heath (agency/organization) name further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Nelehboreare Heath Print Name: Ka ao Title, Cit Opoaing Once Signature: Date: Augut 14,2019, District Representative: L)\\\ve _S. ea\s itle: Sunt Crdonetor Program and Work Lof&tiont, S\ an * Coenn ma Lect Date: _ {fro Signature: Date: _}4 } 2013 accessible through The Source RRR Exhibit A: Student informa tee APPENDIX A. Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Osesse Brown Gitren's Cle (agency/organization name), dated Auut14.2019 Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Odessa Grow Chiro’ Cine (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been {identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. ‘Odessa Brown Chidren's Cnc (agency/organization name) agrees that any educational records received from the District are considered confidential student information Protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Odessa Brown Children’s Clinic. (agency/organization) name further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement (or upon request from the District. Organization: tessa Srown Chidron's Cine Print Name; Kote Title: Inter Adminisvatve Decor Date: August 14,2013 a hClLe District Representative: WJ Program and Work Date: _{} 4 | 2003 ‘Signature: Date:_ 4 Jers Exhibit A: Student inforfétion accessible through The Source © ESSE4 a APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Publ Heath Seat & King Couniy (agency/organization name), dated 3013 Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the schoo! currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. ‘The parties agree that Publle Heath Seale & King County __ (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Pubic Heath Sette & King County (agency/organization name) agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order, Public Heath Seat & King County (agency/organization) name further agrees to retum or destroy any student educational records obtained through the District atthe end of the Agreement or upon request from the District. Organization: Publ Heath Seattle & Kng County Print Name: linia St cir Date: #2/t3 resentative: Walle Sex 1> Tr tite: Grout Cordincey ion: Sin Guamensls | JSCEE Date:_ 1/4 /r13 Date: /4/2903 Signature: District Program and Work Signature:Wy SEATTLE PUBLIC. SCHON, Swepis-| APPENDIX A ‘Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and @sterd Teen Heath Genter at Bana High Senot (agency/organization name), dated Avgus 1.2013 Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the purposes of suppor, including tutoring, and following any education plan provided by the teaching staff of" the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff The parties agree that Sar Teen Heath Connr (ageney/organization name) will have access 10 student educational records (Exhibit A) for District students waa have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served, ‘The parties grce that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools, Bald Teen Mesh Cancer (ageney/organization name) agrees that any ‘educational records received from the District arc considered confidential student information protected by federal law. the Family Educational Rights and Privacy Act (*PERPA") (20 USC. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless Fequired to make such a disclosure under an applicable law or court arder, rd Teen 66th Can (ayency/organization) name further agrees to return ot 'stroy any student educational records obtained through the District at the end of the Agreement ‘oF upon request from the District Organization: Satars Teen Heath Contr Print Name; Sarah Bocbor Tile: Potent Senices Coorinatar _ Date; Aust. 209 Walle Seals Tite: Gals Coord akey ion: Soo] 7 Commonly /JSCEE_ date: “4/4 [2913 9}4 [23 Ew Dat Signature: Exhibit A: Student information accessible through The Source4 We APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student ‘support between the Seattle Schoo! District and Kis Co. @ ToPS (agency/organization name), dated May 8,2013 Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of Support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Kids Co. @ TOPS (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records ean culy be used to perform the educational services described in their agreement with Seattle Public Schools. _Kice Go. @ TORS _ (agency/organization name) agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (*FERPA") (20 US.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unlese required to make such a disclosure under an applicable law or court order. Kids Co. @ TOPS __ (agency/organization) name further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Mids C0. @ TORS. Organizatio Print Name: Jenesre Kvehoss Title: PopomMeraper Signature: OQ Wa Date: May 8, 2013 District Representative: Title: Program and Work Location: Signature: Exhibit A: Student information accessible through The Sourcerial at APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Kids Co. @ John Muir {agency/organization name), dated May 82013 Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. ‘The parties agree that is Co.@ Jotn Muir (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools, ids Co. @ vot Muir (agency/organization name) agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. § 1232) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Kids Co. @ John Mir (agency/organization) name further agrees to return ot destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Ks Co. @ John Mur Print Name: TimZem Title: Program Manager Signature: Date: Maya, 2013, District Representative: Program and Work Location: Signature: Exhibit.re ERE APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Kits Co. @ Granam Hi (agency/organization name), dated May®, 2013 ‘Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named ageney and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Kiés Co. @ Graham Ha (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Kids Co. @ Graham Hi (ageney/organization name) agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Kids Co. @ Grahaen Hi (agency/organization) name further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: is Co. @ Geahom Hi Print Name: Thomas Ko Title: Progam Manager Signature: Date: May 2019 District Representative: __Title: Program and Work Locatioi Signature Exhibit A: Student information accessible through The Sourceaf ie APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Kis Go. @ Linco (agency/organization name), dated May 8, 2013 Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff-can disclose any student educational records to their staff. The parties agree that Kis Co. @ Lncoin (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public (agency/organization name) agrees that any ed from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Kids Co. @ Lincsin (agency/organization) name further agrees to return or destroy any student educational records obtained through the District atthe end of the Agreement or upon request from the District. Organization: Kids 60. @ Lincain Print Name: LaFawpda Witlams _Title: Program Manager Date: May, 2013, District Representative: Title: Program and Work Location: Signature: Exhibit A: Student information accessible through The Sourcear is APPENDIX A. Agreement to Comply with the Federal Educ: nal Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Kits Ca. @ McDonald (agency/organization name), dated May®, 2013 ——__ eyez Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of Support, ineluding tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Ie Co. @ McDonald _ (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. ie Co. @ MeDonad (agency/organization name) agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Kids Co. @ MeDonald (ageney/organization) name further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District Organization: Kis Co. @ McDonald Print Name: LeFawna Wits Title: Progam Manager Date: May 8, 2019 District Representative: Title: Date: Program and Work Location: Signature: Exhibit A: Student information accesible through The Source |S sanare ies APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Kids Co. @ John Hay (agency/organization name), dated May@, 2013 Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. ‘The parties agree that Kiss Co. @ John (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Kids Co. @ John Hay (ageney/organization name) agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Kids Co. @ John Hay ___ {agency/organization) name further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. ‘Organization: Kids Co. @ John Hay Print Name: Niki Bautista Program Mansoor Signatur Date: May 2013 District Representative: Tith Program and Work Location: Date: __ Signature: Date Exhibit A: Student information accessible through The Source BIRSSSSSS Bin staatAPPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutwally-agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Kids Co. @ Queen Anne (egency/organization name), dated Moy8.2013 : Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named ageney and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Kids Co. @ Queen Ame (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Kids Co. @ Queen Anne (agency/organization name) agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. ds Co.@ Queen Anne (agency/organization) name further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Kis Co. @ Queen Anne Print Name; se Title: Progam Manager Signature: Date: May8, 2019, 7 District Representative: Dawicl ELLiot+ Title:_Tiner a Program and Work Location: Date: Signature: Date: Exhibit tudent information accessible through The Source [Jwe ee APPENDIX A. Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Kiés Co. @ Adams (agency/organization name), dated May, 2013 Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff, ‘The parties agree that Kies Co. @ Adams (ageney/organization name) will hhave access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools Kids Co. @ Adams (agency/organization name) agrees that any ‘educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. § 12328) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. “Kids Co. @ Adams (agency/organization) name further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement ‘or upon request from the District. Organization: Kids Co. @ Adams Print Name: Monica Tutey Title: Preoram Mensner _ Signature: \-AOW Date: May 8, 2013, District Representative: Program and Work Location: Signature: Exhibit A: Student information accessible through The SourcebY SEATTLE PUBLIC SCHOOLS APPENDIX A. Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually-agreed upon addendum to an agreement for family involvement and student Support between the Seattle School District and Coaltion for Rekugees from Burma (agency/organization name), dated 04-08-2013 Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. ‘The parties agree that Cosliton or Refugees ftom Suma (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The schoo! will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Publi Schools. Calton for Retugens rom Suma (agency/organization name) agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Coniton or Reto fom Burne (agency/organization) name further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Coatton for Refugees fram Burma ‘Siobhan Whalen Title: Youth Program Coordinator Print Name Signature: Yea Weve Date: 04002018 District Representative: Li Title: Rofugee impact Consulting Teacher Program and Work me Pune Senois_ Date: 04-082013 pa: fap accessible through The Source { Print Signature: Exhibit Az Student informatiSEATTLE PUBLIC APPENDIX A Agreement (o Comply with the Federal Educational Rights and Privacy Act "iss tly aed pon edn agency ay inane ands Suppor betwrean the Seattle School District and 1d shelter) {agency/organization name), dated h Community Based Organizations offering services to Seattle Public School students, and following all school district policies and procedures for engaging students for the purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff The parties agree that PIGOGV 12S Se lte/zency/organization name) wilt have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Sghools. 7 t Shelter _cagency/organization name) agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 US.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required tq make such a disclosure under an applicable law or court order. Broodvien) shelter (agency/organization) name further agrees to relurn or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Print Name: none. Ae” Adverg < bail Sime Malis Lue fb cy oak District Representative Cate nuer rine Sebel +Cor. Parfomd pst Program and Work Location; I S82 Date: Signature: 2S —___pate:_9-2-13 Exhibit Student infor ‘accessible through The SourceAPPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Catholic Community Services Youth Tutoring Program (YTP) dated 09/10/2012. Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that YTP will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this Program. The school will provide a written list or email of students to be served. The Parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. YTP staff agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (‘FERPA’) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such'a disclosure under an applicable law or court order. YTP staff further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Catholic Community Services Youth Tutoring Program (YTP) Title: Youth Services Division Assistant Date: Q/\O/20v7_ ~~ site: Mop, Scents Gt. Peoochiy Date: _%/&-/2 G1 B12 Print Name: Theresa Brennan Signature: District Representative: Program and Work Location: Signature: qurten Exhibit A: ‘Student information accessible through The Source July 2012ee eee September 25, 2012 Dear Ms. Cameron, Enclosed is the information regarding FERPA authorization for local centers of the Youth Tutoring Program of Catholic Community Services of King County. Attachments include a student information list (subdivided by program representative) and the individual parent authorization forms. Please do not hesitate to contact me with any questions or concerns, Sincerely, ZZ ‘Theresa Brennan Youth Services Division Assistant Catholic Community Services of King County 206.328.5953 www.ccsww.org, P Visit us on the web: wwweytpsett “sae aoe ‘races 100 - 23rd Avenue South, Seattle, WA 98144-2302 » (206) 328-5719 » Fax (206) 2aams | MD ESAPPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Arts Corps dated November 16, 2012. Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Arts Corps will have access to student educational records (Exhibit A) for District students who have been identified by the school for the Purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. Arts Corps agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (“FERPA”) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other Person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. Arts Corps further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District Organization: Arts Corps Print Name: Elizabeth Whitford __ litle: Executive Director Signature: date: _U/o/iz District Representative: Cooke Gomer Tie: La Schr tol + Can Peck SSCLE [e27e Program and Work Location; Date: Signature: ry SS Date:_//-2 Exhibit A: ‘Student information accessible through The Source July 2012Lo aay Make Art Anyway CORPS November 19, 2012 Courtney Cameron Office of School and Community Partnerships Seattle Public Schools Mail Stop 32-195 PO Box 34165, Seattle, WA 98124-1165 Re: Access to Student Data Dear Courtney, | am requesting access to student records on the Source for Arts Corps’ Creative Schools Initiative at Madrona K-8 and Orca K-8 in addition to after school arts education programs at multiple school sites. Enclosed, please find: * Our Appendix A agreement ‘+ Two student information lists (separate list for each coordinator) * Individual parent authorization forms arranged by student last name for each information list. !f you have any questions please contact Leslie Collins at 206-722-5440 extension 101, or leslie.collins@artscorps.org. Thank you, Elizabeth Whitford Executive Arts Corps i a SO1(8 tax-exempt organization, Contribution to Arts Corps at tax deductible, +408 Delridge Way SW, #110, Seale WA 98106 p:206 7225440 £206 722 5459 www anscorpe orgAPPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is @ mutually agreed upon addendum to an agreement for family involvement and student support, between the Seattle School District and _/“ i ic cal: agency dated a CPPS Community Based Organizations offering servicés to Seattle Public School students, and follswing all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that__C'PP: (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (‘FERPA’) (20 U.S.C. § 12329) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: CPPS Print Name: Signature: Date:_i2 - jf (2 District Representative: Program and Work gc Signature: Date:_/- 50-/= Exhibit A: Student information accessible through The Source July 2012APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and st ent ypport between the Seattle Schoo! District and Ks S @ John Huir agency dated 2/21/13 5 Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that__Kids > @ John Hui (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served, The parties agree that such student educational records can only be used to perform the educational services described it their agreement with Seatle Public Schools. Kids G @ K wa i” agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act (‘FERPA’) (20 U.S.C. § 12329) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to mgkp such @ disclosure under an applicable law or court order. u @_Jshn Muiv further agrees to return or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Kids G nw Muir Print Name: im Zeyn Title: Pro grams Manager Signature: —T Date:__ 2/2: //3 District Representative: AGa.4 < Woe mean Title’ Runes A Program and Work Location: S=wa WS EL. Date:_al ap. Signature: Que a Wasa ps Date: Exhibit A: 7 (y Student information accessible through The Source July 2012APPENDIX A Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and Coll Now agency dated i Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the schoo! currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that Coll: oss Ni (agency/organization name) will have access to student educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that Such student educational records can only be used to perform the educational Services described in their agreement with Seattle Public Schools. le agrees that any educational records received from the District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA") (20 U.S.C. § 12329) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, Unlefs teduired to make such a disclosure under an applicable taw or court order. Co Lene Access Nani further agrees to retum or destroy any student educatiorlal records obtained through the District at the end of the Agreement or upon request from the District. Organization: \eae Yous) Print Name: Title: Prag (am, S sper isc Signature: Date: \0/9/{2 District Representative: Jill Huds Title: Princ. ipa Program and Work Location: Natvan Hale WS Date: 10/9/12 f, “6? Signature: See Afr ——— Date: ef lt 2 — B Exhibit A: Student information accessible through The Source \ July 2012| | APPENDIX A @ ‘Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and College Access Now agency dated 11 jo6/ 20,2 Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that__ Colle En Access Now (agency/organization name) will have access to student dducational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools, le eves wa agrees that any educational records received from the District are considered confidential student information protected by federal @ law, the Family Educational Rights and Privacy Act (‘FERPA’) (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. College Apeess Now further agrees to return or destroy any student educattnal records obtained through the District at the end of the Agreement or upon request from the District. Organization: Colle Access wy Print Name. _ i Title: Programs Superurse -—Feanltlin HS Signature: v Date:_I\/ob/ 2012 District Representative: Program and Work Locati Signature: Exhibit A: bea Student information accessible through The Source (: a { (il a uly 2012APPENDIX A ‘Agreement to Comply with the Federal Educational Rights and Privacy Act This is a mutually agreed upon addendum to an agreement for family involvement and student support between the Seattle School District and N: agency dated [Q/@/j2. Community Based Organizations offering services to Seattle Public School students, and following all schoo! district policies and procedures for engaging students for the Purposes of support, including tutoring, and following any education plan provided by the teaching staff of the school currently attended, and acting within the agreed scope of work existing between the named agency and Seattle Public Schools need to sign the following agreement before Seattle Public School staff can disclose any student educational records to their staff. The parties agree that (9 eae Nccess Now (agency/organization name) will have access to stutient educational records (Exhibit A) for District students who have been identified by the school for the purposes of this program. The school will provide a written list or email of students to be served. The parties agree that such student educational records can only be used to perform the educational services described in their agreement with Seattle Public Schools. C agrees that any educational records received from thé District are considered confidential student information protected by federal law, the Family Educational Rights and Privacy Act ("FERPA") (20 U.S.C. § 1232g) and that student educational records received from the District will not be disclosed to any other person, agency, or entity without the prior written consent of the District, unless required to make such a disclosure under an applicable law or court order. further agrees to retum or destroy any student educational records obtained through the District at the end of the Agreement or upon request from the District. Organization: Gallego Prcess, Now _ —____. Print Name: 0 Title: Kroqram Supervisor Signature: Date: (0/8/12 Distict Representative: Chacis Viasen, Title: Principal Program and Work Location: Princical, (niet Sealtin IMS Date: \o/a/\Z. Signature: ea Date: \0/A/\Z Student information accessible through The Source July 2012