Release of Information

Authorization for Release of Information

Information to be released to/from:

School/Company:(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number:(Required)

Student Name(Required)

First Last

Date of Birth:(Required)

Gender(Required)

Grade(Required)

Records to be released:

Transcript of Grades
Grades (most recent)
Attendance
Birth Certificate
Health and Medical Records (Including immunizations)
Special
Gifted/Talented records
Education Records such as:

Current IEP
Educational evaluations
Psychological evaluations
Socio/development records
Treatment records

Discuss educational information

Parent Name:(Required)

Contact

Academics

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