Consent to Release and Exchange of Information (Paw Pantry)

Consent to Release and Exchange of Information

A copy of this form is considered as valid as the original. The Contact Person will send copies of this form to all individuals/agencies listed below. Individuals/agencies listed are responsible for providing requested information.

We want to protect student and family confidentiality, while complying with both state and federal law, including but not limited to the Privacy Act of 1974, specifically the Family Educational Rights and Privacy Act (FERPA By signing this form, you are giving permission to the individual(s)/organization(s)/agency(ies) listed below to share information which would otherwise be confidential.
Child/Student*

Legal First NameMiddle NameLegal Last Name
Birthday*

MonthDayYear
Date

Release and Exchange of Information
- I give permission for the parties named below to release and receive written and verbal information regarding the above-named child/student for the release and exchange of educational records and program information to coordinate after school activities within the school day.
- I understand I may revoke permission by giving written notice to each party named below. I understand the contact person below can direct me to the shared information upon request.
Contact Person*
Phone Number*
Please enter a valid phone number.
Position/Agency*
Email*
example@example.com

Agencies and Organizations
- The following agencies and organizations will collaborate in planning, coordinating, and delivering services to students receiving services being administered by Clear Lake Community School District. Therefore, this form permits the use, disclosure, and redisclosure of confidential information for the above purpose and delivery of said services.
- I understand that state and federal law prohibits persons who receive mental health, alcohol or drug abuse, and educational records from redisclosing those records without permission. I also understand that not every organization that may receive a record is required to follow federal HIPAA rules governing the use and disclosure of protected health information. [HIPAA is a federal law intended to protect the confidentiality of health care information.]
- I HEREBY GIVE PERMISSION TO THE PERSON(S), AGENCY(IES), AND ORGANIZATION(S) THAT RECEIVE RECORDS PURSUANT TO THIS AUTHORIZATION TO RELEASE AND REDISCLOSE THAT RECORD AND THE INFORMATION IN THAT RECORD TO OTHER PERSONS, ORGANIZATIONS, OR AGENCIES LISTED HEREIN FOR THE PURPOSES OUTLINED ABOVE, BUT FOR NO OTHER PURPOSE WHATSOEVER.
Agency 1
Name of Individual and/or Agency
Address & Phone
Info to Share
Agency 2
Name of Individual and/or Agency
Address & Phone
Info to Share
Agency 3
Name of Individual and/or Agency
Address & Phone
Info to Share
Agency 4
Name of Individual and/or Agency
Address & Phone
Info to Share
- I understand that this permission and release is valid for one year following its execution and that this permission and release will expire one year from today’s date.
- I understand that this permission and release may be revoked.
- I understand that if this permission is revoked, it may not be possible to continue to participate in certain programs. I will be informed of that possibility if I wish to revoke this permission.
- I also understand that records disclosed before this permission is revoked may not be retrieved. Any person, agency, or organization that relied on this permission may continue to use records and protected information as needed to complete work that began prior to the revocation of this permission.
Parent/Legal Guardian Signature*

Draw signature with your finger or mouse.
Date

MonthDayYear
Date
Student Signature*

Draw signature with your finger or mouse.
Date

MonthDayYear
Date

Specific Authorization for Release of Information Protected by State or Federal Law
My signature authorizes the release of all information relating to (check appropriate boxes)

Mental Health/PsychologicalSubstance AbuseHIV Status/AIDS related testingOther
Parent/Legal Guardian Signature*

Draw signature with your finger or mouse.
MonthDayYear
Date
Student Signature*

Draw signature with your finger or mouse.
Date

MonthDayYear
Date
Witness*
Name of Individual and/or Position and Agency
Date*

MonthDayYear
This field cannot be edited.
Should be Empty:

Release and Exchange of Information

Agencies and Organizations

Specific Authorization for Release of Information Protected by State or Federal Law