Mutual Release of Information by gqm11330


More Info
									Appendix F Section V Question 6

                             SES Tutoring Mutual Release of Information Form

TO:                  SES provider                                        FROM:              Receiving School

                     __________________                                                     __________________

                     __________________                                                     __________________
                     (School Name)                                                          (School Name)

                     __________________                                                     __________________
                     (Address)                                                              (Address)

                     _____________________                                                  _____________________
                     (City, State, Zip Code)                                                (City, State, Zip Code)

Regarding:           __________________                                                     __________________
                     (Student’s Name)                                                       (Date of Birth)

                     ______________________                                                 _____________________
                     (Address)                                                              (Grade)

                     ______________________                                                 _____________________
                     (City, State, Zip Code)                                                (School)

Purpose: To give SES instructors and the tutoring provider academic information for students
participating in SES tutoring.

Please release the records indicated below and forward them to the tutoring provider.

      Personal Identifying Data                                                                            Academic Work
      Standardized Achievement Test Scores                                                                 Attendance Data
      Medical Records (Psychiatric, Neurological, Etc.                                                     Legal Records
      Psychological Records                                                                                Discipline Record
      Special Education Records                                                                            Behavioral Records
      (IEP, IEP Committee Reports, Annual Review, Consents, etc)


Authorization Statement and Signature

I understand that under the Family Education Rights and Privacy Act (FERPA), all information, records and
documents received under this release are confidential but will be available for inspection and review by the
student’s parent(s)/guardian(s) and eligible student, or the authorized representative of the parent or eligible

Authorized representatives of the organization/agency to which the records are released will have access to these
records. No other parties, however, will have access without my knowledge or consent, unless authorized to have
access under FERPA.

_______________________________________________                            _____________________________________
(Signature of Authorized School Representative Requesting Information)     (Signature of Parent or Guardian)      (Date)

__________________________________________________________                 _______________________________________________
 (Date)                                                                    (Signature of Student, if 18 years of age or older) (Date)

To top