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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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			Jump to a new section --[ Getting Around ]-- Home Page What's New Privacy Policy Search --[ People ]-- Family Support Network Adults with Diabetes Care Photos Chat Rooms Conferences Kids with Diabetes Parents Parent Humor Scholarships and Financial Aid Grandparents Humorous Tidbits Jobs Mailing Lists CWD Forums Poetry and Art Videos Polls Quilt for Life Surveys Blogs --[ Clinic ]-- Ask the Diabetes Team Alternate Site Testing Alternative Treatments Care Suggestions CWD Español Diabetes Basics Diabetes at School 504 Plans Diabetes Camps Diabetes Dictionary Insulin Pumps Nutrition Podcasts Presentations Products Product Marketplace Sports Studies Warning Signs --[ Sources ]-- News and Information Diabetes Advocacy Links to Other Web Sites Press Releases Regional Information Services Support Groups --[ Feedback ]-- About CWD Advertise Awards Contribute Your Experiences Disclaimer Letters to the Editor Logos and Linking Share our Brochures

Last Updated: Wednesday November 26, 2003 09:44:12
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