2024/25 Authorized Release Form

WASHTENAW ALLIANCE FOR VIRTUAL EDUCATION
301 W. Michigan Ave Suite 201 Ypsilanti, MI 48197

PH. (734)761-7027 FAX. (734) 483-1464

Authorized Release & Exchange of Information
Student
First, Last
Birth Date

MonthDayYear
Date
Student Phone
Format: (000) 000-0000.
Home Address
Parent or Guardian
Phone
Format: (000) 000-0000.
Email Address
example@example.com
Last School Attended
Please send the following records to waveoffice@weocflex.org or fax to 734-483-1464
IEP/504
IEP?
504?
| am authorized to release such information as a parent with custody or legally authorized guardian. My authorization is voluntary and shall be effective for one year from the date of this form and must be obtained annually. I can revoke this authorization at any time. Revocations must be made in writing and sent to the address listed at the top of this form. Revocations will not apply to information that already has been released. I also understand that re-disclosure of this information to a party other than the one designed above is forbidden without additional written authorization on my part.
Parent Print Name
Print Witness Name
Parent Signature
Print Witness Signature
Date

MonthDayYear
Date
Should be Empty:

WASHTENAW ALLIANCE FOR VIRTUAL EDUCATION