PINE CITY PUBLIC SCHOOLS

PINE CITY PUBLIC SCHOOLS

Darlene Smetana

Food Service Director

1400 S. Main Street

Pine City, MN 55063

(320) 629-4167

Email Release Form

The Federal Education Rights and Privacy Act is intended to insure the privacy of personal financial information, by specifically preventing employees or staff of Pine City Schools from releasing details or discussing the status of individual financial accounts with anyone other than the individuals included in the account and appropriate employees and staff. In addition, Pine City Schools may not send emails containing such information, nor respond to email requests for such information, unless an email information release form is on file in the Food Service Department. If you have a current email address and you would like to be kept informed of your lunch account status by email, and have the School District and/or Food Service department use it to correspond with you, please complete the following form.

Last Name________________________________________

First name________________________________________

Mailing Address___________________________________

City, State, Zip____________________________________

Email Address____________________________________

Certification: I hereby request that the Pine City School District and the department to which I am applying accept this authorization to release confidential financial information to me, related to my school lunch account, via the email address listed above. I understand that electronic mail is a less secure environment than the postal service. Pine City Schools, its faculty and staff, the Pine City School District, and ISD 578 are not held liable for the release of information permitted by this agreement. This release form stays in effect until revoked by me in writing, or through email notification, or verbal authorization. If I should leave or transfer from Pine City School District for any reason, this release form is no longer valid.

Signature_______________________________________

Date Signed_____________________________________