Marysville School District
Marysville School District
WORK-BASED LEARNING
CONFIDENTIAL RELEASE OF INFORMATION
Marysville-Pilchuck High School
The Transition to Success/Work Experience Connections programs provides on site employment training to students as part of their plan for graduation and transition to post secondary employment and education. In order to meet the needs of the students in this community based work setting, it is important to share some information about your son/daughter with each employer. This information assists the employer in understanding the specific needs of the students, and in providing for a safe working environment. Only information specific to the student’s individual needs that is related to their education/training at the work experience site will be shared with each employer.
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The Transition to Success/Work Experience Connections program of the Marysville School District has my permission to provide pertinent confidential information to the employer of the work based learning site that will guide in the development of skills necessary for my son/daughter’s learning/training and safety in the workplace. I understand that the information provided to the employer will be treated in a confidential manner. The information that will be provided to the employer is indicated below:
______ Basic Academic Skill Levels
______ Physical/Medical Needs
______ General Behavioral Concerns/Needs
______ Other_________________________________________________
______________________________________________________
______ I give my consent ______ I do not give my consent
Parent Name Parent Signature Date
Student Name Student Signature Date
WBL Coordinator Name WBL Coordinator Signature Date
The Marysville School District, as an educational institution and as an employer does not discriminate on the basis of race, religion, ethnicity, national origin, age, disability, sex, marital or veteran status. This is a commitment made by the district in accordance with federal, state and local laws and regulations.