Date Sent/Mailed:
Student’s Name: DOB:
School: Grade:

We are asking that you authorize the person or agency named below to release specified records containing confidential information regarding the above named student:

Information Requested From:     ______________________________

______________________________

______________________________

spacer
Send Requested Information To:     ______________________________

______________________________

______________________________

______________________________

Records requested:  [  ] Medical/health history     [  ] Reports
Purpose of disclosure: Assist in providing appropriate health care in the school setting.

Please check Yes only if you agree that the statements are correct. If the statements are not correct, check No. If you wish to have more information or if you have any questions, please call ___________________________________________ at _____________________.

  Yes   No
spacer
[  ] [  ] I have been fully informed and do understand the school’s request for my consent for release of my child’s records, as described above. This information will be released upon reciept of my written consent.
spacer
[  ] [  ] I understand that my consent is voluntary and may be revoked in writing at any time.

 

________________________________ _____________
Signature of Parent/Guardian Date
spacer
________________________________ _____________
Signature of Interpreter, if Used Date

Please send requested information to the address above as soon as possible.