Beaufort Jasper EOC Head Start

Beaufort Jasper EOC Head Start
Parental Consent to Release and Receive Information
Child(s) Name*
Child DOB*

MonthDayYear
Date
Parent Name*
Register Program (HS/EHS)*
HS Center*
EHS Center*
I, {parentName}, give permission to release or receive all personally identifiable information indicated below in reference to my child born, {date} to the organizations and/or individuals listed below.

This consent gives Beaufort-Jasper EOC Head Start permission to release the following records regarding my child to the Beaufort and/ or Jasper County School District, and, gives permission to the Beaufort and/ or Jasper County School District to release the following records regarding my child through the third grade to Beaufort-Jasper EOC Head Start.

Release or Receipt of information between:

*Baby Net (Children birth to 3 years old)
*Department of Social Services
*Early Interventionist

Information to be released or received:

*Educational and/or Developmental Screenings Result
*Evaluation Results
*Educational Assessment Scores
*IEP/IFSP
*Hearing/Vision Screenings and/or Results
*Certificate of Immunization
*Medical Records
*Copy of Birth Certificate
The information being released or received will assist the organizations listed in gathering information for school enrollment and/or transition, record keeping, and data collection purposes for continuous program improvement. Yes, I confirm that I have read and understand this form. By checking this box, I am electronically signing this form.
Parent Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Beaufort Jasper EOC Head Start

Parental Consent to Release and Receive Information