Student Release Form Lavelle – Brother Kearney Scholarship Program Waiver/Release of Information Students seeking to obtain funding from the Lavelle-Brother Kearney Scholarship Program must authorize the release of the following information to the Lavelle Fund for the Blind on an as-requested basis: Education data from the student’s high school, college/university, including personally identifiable information such as grades, transcripts, enrollment status and any information pertaining to the applicant’s education at other institutions previously attended Financial aid data from the college/university in determination of the Scholarship amount Evaluation and assessment information from professionals who have interacted with the applicant including (but not limited to) parents, Vocational Rehabilitation Counselors, teachers, Disability Services representatives, technology instructors, and orientation and mobility instructors Employment data from the college/university, external service provider, and/or state Vocational Rehabilitation office, including details of internships held during undergraduate/graduate studies and jobs obtained up to 5 years after program completion. Consent to Release Information and Waiver of RightsI hereby authorize The Lavelle Fund for the Blind to receive information as indicated above upon request for the purpose of Scholarship determination and administration, and outcomes assessment of the Lavelle - Brother Kearney Scholarship Program. I agree to release this information without further consent and until further written notice. This authorization shall be considered as a waiver of any and all my rights and/or privileges including the right to access confidential references given for any of the purposes listed above.Name of Student (required)* First Name: Last Name: Date: Date Format: MM slash DD slash YYYY Signature of Student:Name of Legal Guardian (if applicant is under 18 years) First Name: Last Name: Date: Date Format: MM slash DD slash YYYY Signature of Legal Guardian:PhoneThis field is for validation purposes and should be left unchanged.
