Student Release Form


Student Release Form for Colleges Participating in the Brother James Kearney Scholarship for the Blind

  • In line with the Brother Kearney Scholarship Program’s requirements, I agree to release and provide my college’s Disability Services Office) with the following information:

    • education data, such as grades and transcripts, and enrollment status.
    • employment data, including details on internships held during my undergraduate/graduate studies and jobs obtained after college graduation.

    My university/college and/or the Lavelle Fund may request such data at any time during my college career. In addition, I commit to providing appropriate education and employment data at three specific times: (1) when I graduate (or withdraw) from the university/college, (2) one year after such graduation, and (3) at any other time, within five years of my graduation, at which my university/college may decide to seek such data through alumni surveys.

    My signature below also authorizes my university/college to exercise its best efforts to transmit the aforementioned data to the Lavelle Fund when requested by its authorized officers, directors, and employees, and it is my understanding that my college will retain and release such data in accordance with my rights under the Family Educational Rights and Privacy Act (FERPA).

  • Including field of study, if not self-evident.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.