Student Release Form - Lavelle Fund for the Blind

Name of Student (required)*

First Middle Last

Name of College (required)*

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).

College Outcomes ‑ Major:

College Outcomes – Degree Earned (if any):

College Outcomes – Degree Date Conferred - Year:

College Outcomes – Degree Date Conferred - Month:

Employment Outcomes – Job Title (if employed):

Employment Outcomes – Name of Employer:

Employment Outcomes – Full or Part-time:

Employment Outcomes – If seeking work, list vocational objective:

Advanced Education Outcomes – Degree Sought:

Including field of study, if not self-evident.

Advanced Education Outcomes – Name of College or University:

Advanced Education Outcomes – Degree Earned:

Advanced Education Outcomes – Degree Date Conferred - Year:

Advanced Education Outcomes – Degree Date Conferred - Month:

Other Status – If Not Currently Employed Or Studying:

Signature of Student:

Date

Witnessed by:

Date

Phone

This field is for validation purposes and should be left unchanged.