School Release of Information Form

School Release of Information Form
Authorize the release of student records or information to a designated recipient.
Student Full Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Recipient Name
First NameLast Name
Recipient Relationship to Student
Recipient Contact Information (Email or Phone)
Description of Records or Information to be Released
Reason for Release
Parent/Guardian or Student Name (if 18 or older)
First NameLast Name
Date of Authorization
MonthDayYear
Date
Should be Empty: