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| Student Name: | DOB: | ||
| School: | * | Grade: | * |
I hereby authorize the release/exchange of confidential educational, medical, and/or mental health information for the above-named student.
1. Organization(s) or person(s) allowed to release the information indicated by this form:
☐ Everett School District ☐ Other: Name: Address: Phone: Fax:
2. Organization(s) or person(s) to receive the information indicated on by this form:
☐ Everett School District ☐ Other: Name: Address: _______________________________________ Phone: __________________________________ Fax: _______________________________________
3. Specific description of the educational, medical, and/or mental health information that may be used or disclosed:
☐ Report Card/Transcript/Attendance ☐ Occupational Therapy Report ☐ Current IEP & Evaluation Reports ☐ Physical Therapy Report ☐ Behavior Report ☐ Speech/Language Report ☐ Educational Assessment Report ☐ Psychological Report ☐ Hospital or Clinic Report/Records ☐ Health/Medical Social Report ☐ Health Records/Immunizations ☐ Other:
4. The information will be used or disclosed for the following purpose(s):
☐ At the request or direction of the undersigned individual ☐ To plan an appropriate educational program addressing special needs and/or attendance ☐ Other: ______________________________________________________________
5. I acknowledge notification of this transfer of records as required by the Family Educational Right and Privacy Act of 1974 and understand that I have a right to receive a copy at my own expense if requested and to contest any information I feel is incorrect. This medical authorization is valid for the academic year for the stated reasons of the request unless revoked in writing. All records received will become part of the student’s file. I understand that once the health information I have authorized to be disclosed reaches the noted recipient, that person or organization may re-disclose it, at which time it may no longer be protected under Privacy laws. I can cancel this authorization at any time in writing. I understand that once the information has been released according to the terms of this authorization, the information cannot be recalled.
Name of Parent/Guardian or Student (13+) Relationship to Student Parent/Guardian or Student Signature (13+) Date Name of Requestor and Title Requestor Signature Date
**If the student’s records contain any of the following information, that student or student’s authorized representative must express written consent by checking below and signing.
☐ HIV/Aids status, diagnosis, treatment (age 14 or older) ☐ Alcohol/drug treatment (age 13 or older) ☐ Family Planning/abortion (no minimum age) ☐ Mental Health Services (age 13 or older)
| ______________________________________________________ | |
| Signature of Student or Authorized Student Representative Date | |