Free Educational Release Form - Kentucky

7/02

Kentucky Labor Cabinet Department of Workers' Claims Authorization for Release of Educational Information
I, __________________________, having received a retraining incentive benefit award and desiring to participate in retraining do hereby authorize any school, training facility, or person, institution, corporation or governmental agency to disclose or release any requested educational information including grades, training progression, and class attendance and other related educational matters to the Department of Workers Claims, Department of Vocational Rehabilitation, self-insured employer, insurance carrier or Division of Workers Compensation Funds. This authorization includes the examination and copying of any desired documents or records. Signed at ______________________, Kentucky, this the ______________ day of ___________________________, 200____.

_______________________________ Claimant's Signature _______________________________ Social Security Number

_______________________________________ Witness Signature