Consent For Release Of Confidential Information
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: ______________________________
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 [ ] [ ] 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. [ ] [ ] I understand that my consent is voluntary and may be revoked in writing at any time.
________________________________ _____________ Signature of Parent/Guardian Date ________________________________ _____________ Signature of Interpreter, if Used Date
Please send requested information to the address above as soon as possible.
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Last Updated: Wednesday November 26, 2003 09:44:12
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