School Release Form

82 Washington St., Suite 214
Poughkeepsie, NY 12601
845-452-3913 (Voice)
845-485-3196 (Fax)
845-485-8110 (TTY)

Today's Date:

MonthDayYear

E-Mail:

Parent/Guardian Name:

First NameLast Name

Parent Address:

Street Address

Street Address Line 2

CityState

Zip Code

I hereby give permission (you may check off one or both)

To release information and/orTo receive information from

School District*

Person:

Title

School District Address:

Will be filled in automatically

Requested Information

Any relevant information pertaining to the child's education.

Any other specific information you would like us to obtain or release:

Child's Name:

First NameMiddle Name or InitialLast Name

Child's Date of Birth

MonthDayYear

Social Security Number

Information is needed for the purpose of:

To help the child in securing a free and appropriate education.

Default statement for consent

The above statement should be sufficient for us but if you want to specify any other reason to give us consent, you may do so here:

My consent is subject to revocation at any time and will expire in: (we recommend leaving the checked default for 1 year but you may change it.)

60 days90 days6 months1 year

Date

MonthDayYear

Parent's Signature*

* Social Security Number and D.O.B. are required for governmental agencies which includes the Social Security Administration.

Note: For persons receiving treatment for alcohol or drug abuse, any information disclosed as per this release is protected by Federal Law. Federal Regulations (42CFR Part 2) prohibit any re-release or further disclosure of Information without the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose.

We encourage you to Review your Consent form for accuracy by clicking the Review, Print and Save PDF button below. Then you can click on the mini printer icon and for Destination either Print to your local printer on the list or choose to Save as a PDF and save a copy on your computer. Then come back to this page and hit Submit to proceed to Step 3, Completing a Release Form.

INFORMED CONSENT TO RELEASE/RECEIVE INFORMATION