Child Information Release Authorization Form
Authorize the release of your child's information to a designated party. Please complete all required fields.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Legal Guardian
Other
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Recipient (Person or Organization to Receive Information)
*
Recipient's Contact Information
Purpose of Information Release
*
Types of Information to Be Released
*
Academic Records
Medical Records
Attendance Records
Behavioral Reports
Other
Authorization Valid Until (Date)
-
Month
-
Day
Year
Date
Signature of Parent/Guardian
*
Authorize Release
Authorize Release
Should be Empty: