GCQCA-E  Authorization to Disclose Information/Release of Claims/Indemnity

NEPN/NSBA Code: GCQCA-E 

AUTHORIZATION TO DISCLOSE INFORMATION/RELEASE OF CLAIMS/INDEMNITY 

I, ____________________________, hereby request and authorize M.S.A.D. #4 and its past, present, and future school boards, school board members, employees, and agents, both in their individual and official capacities, (hereinafter separately and collectively referred to as the “District”) to provide any information which is directly or indirectly related to my employment and the termination of my employment with M.S.A.D. #4, including without limitation information which would otherwise be confidential by statute, contract or otherwise, to anyone making an inquiry regarding my seeking employment. Such information may include facts or opinions about my performance, character, conduct, both at and apart from school activities, and my suitability for various employment positions. The District may provide such information in response to either oral or written requests and may rely on the oral representation of the person requesting information that I am seeking employment. I understand and agree that the District is not required to either notify me when it provides such information or review such information with me and that it does not plan on doing so.

In consideration for the District providing such information, I, for myself, my heirs, successors, assigns, and personal representatives, expressly waive and release the District from any and all claims, including without limitation claims for defamation, emotional distress, invasion of privacy, violations of constitutional rights, violations of statutes or interference with contractual relations (and including claims based on or alleging negligence) which in any way arise out of the District providing the information described above, and I also agree to indemnify and hold harmless the District from any and all expenses, including without limitation reasonable attorneys’ fees which the District may incur as a result of any such claims by me or others. This is not a mutual release; it does not operate as a release of any present or future claims of the District against me.

This authorization/release/indemnity shall remain in effect until receipt by M.S.A.D. #4 of a written revocation from me.


I HAVE CAREFULLY READ AND CONSIDERED THIS 
DOCUMENT BEFORE SIGNING. 


_______________________________________         __________________
Signature                                                                        Date



M.S.A.D. #4