School Release of Information Form/Permission for Third Party Access

I hereby give permission to the staff of ProjectOz 1105 W. Front St. Bloomington, IL 61701 (309) 827-0377 Fax (309) 829-8877 to work with Youth's Name* at School* .

I also consent to the release or obtaining of information from the school staff about this student for the purpose of developing the case.

I understand that I have a right to revoke this authorization at any time and that I must do so in writing to Project Oz. I understand that the revocation will not apply to information already released. Unless otherwise revoked, this authorization is valid for one year and will expire on Date*.

I understand that authorizing the disclosure of this information is voluntary. I can refuse to sign this authorization. I understand that I may inspect or copy the information before it is disclosed. If I have questions about the disclosure of my information, I can contact Project Oz at
(309)827-0377.