New Directions Academy
4000 Hwy 48 N. Charlotte, TN 37036 615-740-6070 Fax 615-789-7032
Transfer School
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Name of the school
Student Name
First Name
Middle Name
Last Name
Student's Date of Birth
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Month
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Day
Year
Date
Parent's Name
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First Name
Last Name
Parent's Name
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First Name
Last Name
I authorize the release of the following records on the above named child to New Directions Academy
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School records (grades, attendance, behavior/discipline records
Special Education Records and Testing
504 Records
Academic testing (including educational evaluations)
Psychological evaluations
Psychiatric evaluations
Mental health counseling and summary reports
Department of Children's Services
Medical Records
Other
I do not authorize the release of the following:
Signature
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Today's Date
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Month
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Day
Year
Date
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