Release of Information Form

Child’s Full Name

Child’s Date of Birth

Name of entities and/or individuals I authorize to receive information.

The purpose of this release of information is for (select all that apply):

Student support and well-being

Educational evaluation and planning

Health assessment and planning for health care services and treatment in school

Medical evaluation and treatment

OtherOther

I give permission for City Academy School to release and/or receive information to and/or from these entities entities and individuals in the form of:

Verbal communication

Academic records

Medical records

Counseling notes or records

Academic testing

Disciplinary/conduct records

Attendance records

Parent/Legal Guardian’s Name

Parent/Legal Guardian’s Email

Signature

Clear

By signing above, I hereby approve of the information contained in this release.

*This authorization expires one year from the date of signature*

I understand that I may revoke this authorization at any time, except to extent that action has already been taken upon it, by submitting written notice of the withdrawal of my consent to City Academy.

Date

If you are human, leave this field blank.

Release of Information Form

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