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   Release of School Records

    

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Release of School Records

Student

Name: _________________________________ Student ID: _________________________________
SSN: _________________________________ DOB: _________________________________
Guardian: _________________________________ Relation: _________________________________
Phone: _________________________________ Email: _________________________________
Address: _________________________________

Transfer From

School: _________________________________ Name: _________________________________
Fax: _________________________________ Email: _________________________________
Phone 1: _________________________________ Phone 2: _________________________________
Address: _________________________________

Transfer To

Name: _________________________________ Organization: _________________________________
Fax: _________________________________ Email: _________________________________
Phone 1: _________________________________ Phone 2: _________________________________
Address: _________________________________

Authorized Information to Disclose

Release of School Records

Grades and Test Scores
Health Records
Discipline Records
Psychological Evaluation/Special Needs
Other:___________________

Reasons for Disclosure

Release of Dental Records

Special Education/Speech Therapy Planning
Disciplinary Ruling
Health Care/Diagnosis
Educational Planning/Applications
Transfer to New School
Other:___________________

I, the student or legal guardian, understand that I may revoke my consent, in writing, at any time. I understand that my information will be held in the strictest confidence and will be read, shared, and held by no parties other than those who transfer the information and those who receive it.

(Student's Signature)

(Legal Guardian's Signature)

(Date)

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