School Release of Information Authorization Form
Authorize your school to release specific information to a designated recipient. Please complete all fields accurately.
Student's Full Name
*
First Name
Last Name
Student's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
School Name
*
Name of Recipient or Organization Authorized to Receive Information
*
Purpose of Information Release
*
Type of Information to be Released
*
Academic Records
Attendance Records
Disciplinary Records
Special Education Records
Other
Relationship to Student
*
Please Select
Parent/Guardian
Student (18 or older)
Other
Your Email Address
*
example@example.com
Today's Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature (Draw your signature below to authorize release)
*
Submit Authorization
Submit Authorization
Should be Empty: