Authorization for
Release and Exchange of Information
I,
__________________________________, declare that I am the parent/legal guardian
(print name of adult)
of
__________________________________, and that my child will receive or is
(print name of student)
receiving
services through ________________________________________________.
(print
name of organization)
1.
I authorize San Francisco Unified School District to release information from
my child’s
educational record to the organization
named above. This information can include:
·
My
child’s name, address, phone number and emergency contact information
·
Name
of school my child is attending and his/her grade level
·
My
child’s daily school attendance information
·
My
child’s grades and report cards
·
Other
(specify): ___________________________________________________
The information disclosed to the organization
will be used for the following purposes:
·
To
assist this program in assessing my child in order to provide him/her with
appropriate services and/or referrals to appropriate services;
·
To
assist this program in providing case management for my child;
·
To
track my child’s progress and provide information necessary for the evaluation
of the effectiveness of this program.
2. I request the following exceptions to
this authorization: ___________________________
_______________________________________________________________________
3. I understand that I am entitled to receive a
copy of this signed authorization form and that this authorization can be revoked at any time, if done in
writing.
Signature:
Parent/Guardian Date
Student
(if 18 or older) Date