BUEDRD

Buford Elementary School
BES Authorization to Release Information
2500 Sawnee Avenue Buford, Georgia 30518 (770) 945-5248 + Fax (770) 932-7579
I hereby authorize {nameOf} to release information/records listed below on my child, {childsName} to Buford Elementary School.

It is understood that the party to whom this information is released will not release it to a third party. These records are needed for:

Development and Implementation of Medical Action Plan

Educational Evaluation

Determination of the most appropriate Total Program for my child

Other: {otherDocuments}
Child's Name*

First NameLast Name
Name of Pre-School*
Other document(s) requested:
I also authorize telephone communication between Buford City School personnel and other professionals who have information about my child.

I understand and agree to the above statement:
Signature*
Date*

MonthDayYear
Date
Should be Empty:

BES Authorization to Release Information