Parent Input Form for Schools/Evals

Parent Input Form for Schools/Evals

Only complete parent input form if you have signed/approved a prior written notice for initial evaluation (or reevaluation) and request for consent form. If you are not sure, please contact the school to confirm. Form Preview
  • COUNCIL ROCK SCHOOL DISTRICT

    Special Services Department

    30 N. Chancellor Street.

    Newtown, PA 18940

    (215) 944-1000

  • PARENTAL AUTHORIZATION

  •  -  -
    Pick a Date

  • This consent will begin the date of this authorization and will expire one year from submission unless revoked by me in the interim. I, the undersigned, hereby acknowledge that I have read this authorization prior to its execution and fully understand the nature of this release. All information released will be handled confidentially in compliance with the Federal Privacy Act (PL 93-380 Sec. 438) and the Pennsylvania Mental Health Procedures Act, and the Federal Educational Rights Privacy Act or FERPA.

    FERPA

  • Clear
  • Clear
  • Clear
  •  -  -
    Pick a Date
  • THIS INFORMATION IS FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED BY FEDERAL LAW. FEDERAL REGULATIONS PROHIBIT MAKING ANY FURTHER DISCLOSURE OF IT WITHOUT THE SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS, OR AS OTHERWISE PERMITTED BY SUCH REGULATIONS (42 CFR Part 2). A GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMATION IS NOT SUFFICIENT.

  • Should be Empty: