Consent to Release Information

Date*

MonthDayYear
Date
I consent to have information concerning
Student's Name *

First NameLast Name
to the Sandwich School District.
Students Birthdate*

MonthDayYear
Date
ParentGuardian Signature*

Clear
Parent Email Address*
example@example.com
Parent/Guardian Contact Phone Number*
Please enter a valid phone number.
Grade level*
Name of Previous School*
Address of previous school*
Phone Number of previous school*
Fax Number or Email address of previous school*
Information requested includes the following:
- Illinois in Good Standing Form (If applicable)
- Health Records
- Scholastic Records
- Confidential Records
- Psychological Records
- Special Education/504 Records
District Office 720 S. Wells St Sandwich, IL 60548 | (815) 786-2187 | Sandwich430.org
Should be Empty: