Release of Confidential Information to Authorized Persons/Organizations

  1. The Los Angeles Scholars Investment Fund (LASIF) is an initiative of the California Community Foundation (CCF), in partnership with College Futures Foundation (“College Futures”), a private not-for-profit foundation dedicated to increasing opportunities for students who are low-income and have had historically low college success rates by removing barriers to college degrees.LASIFhas providedfunding to[INSERT ORGANIZATION NAME]to provide programs and/or scholarships to you.
  1. Consent to the sharing of your information with California Community Foundation and College Futures:By signing and submitting this form, you authorize [INSERT ORGANIZATION NAME] to share all information held by [INSERT ORGANIZATION NAME] relating to you, including all information you provide in yourscholarship application or program registration form including, but not limited to, personal information, such as your name, mailing address, email address and date of birth, high school attended and/or graduated from, information relating to any financial aid awarded to you, and your attendance at any higher education institution (together, your “Personal Information”), with California Community Foundation and its partner, College Futures,for the purpose ofmonitoring the progress of students who receive scholarships and other services funded by California Community Foundationand researching and evaluatingsupports for students to attend and complete college.
  1. Consent to the sharing of your information byCalifornia Community Foundationwith third parties:By signing and submitting this form, you authorize California Community Foundationto share yourPersonal Information with the following third parties, who (as further explained below) either (1) perform similar research or services to those provided byCalifornia Community Foundation, or (2) provide additional information to California Community Foundationabout you or other students generally or otherwise to assist California Community Foundationin advancing knowledge about college going and completion in California:

a)[INSERT ORGANIZATION NAME];

b)Employees and third party services providers of California Community Foundation and College Futures who help to administer and provide its services and programs, such as College Futures’ data management system providers who store and process information (including your Personal Information) on College Futures’ behalf. Employees and third-party services providers of the two Foundations have access to your Personal Information only for the purpose of performing services on their behalf;

c)National Student Clearinghouse in order to verify your admission to, enrollment in and attendance at any college or university;

d)Any higher education institution to which you are admitted for verification of your enrollment and access to information on your academic progress (including transcripts);

e)Entities and government agencies responsible for administering financial aid programs, including the California Student Aid Commission (CSAC), so that California Community Foundation can obtain information from those entities and agencies on your financial aid eligibility, financial aid you receive, and information on any higher education institution with respect to which you receive financial aid;

f)Researchers, institutions and organizations which undertake research on strategies to increase access to and successful completion of college, and which have access to your Personal Information only for the purpose of performing research and are expressly obligated not to use your Personal Information for any other purpose and not to disclose your Personal Information to any third party. As such, although the research results may be made publicly available by these entities or by California Community Foundation, the research results shared in these contexts will not contain or reveal your Personal Information and any information that could identify you will be removed or changed; and

g)Administrative, law enforcement or government agencies to the extent required by law, or any order or requirement of a court or any such agency.

  1. General. This form, and the authorizations contained herein, will remain in effect until you revoke it, which you may do at any time by contacting [INSERT CONTACT NAME AND NUMBER AT ORGANIZATION]. Any waiver, modification or amendment of this form will be effective only if acknowledged in writing by California Community Foundation.Further, you understand that [INSERT ORGANIZATION NAME] will maintain a record of this form, and that you are entitled to request and receive a copy.

This form will be governed by and construed in accordance with the laws of the State of California, excluding that body of law known as conflict of laws. If any provision of this form is found to be invalid or unenforceable, that provision will be enforced to the maximum extent permissible and the other provisions will remain in full force and effect. Failure to enforce any provision of the form will not constitute a waiver of future enforcement of that or any other provision. This form may be executed in counterparts, each of which will be deemed an original, but all of which together will constitute one and the same instrument. Signed signature pages may be transmitted by electronic means, and any such signature shall have the same legal effect as an original.

Student Name: ______

Date of Birth: ______

Parent’s Signature: ______(if student is under 18)

Student’s Signature: ______(if student is 18 or over; if student is emancipated)

Date: ______

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