Permission for Release of information

Permission For Release Of Information
This form will grant New Way Academy permission to exchange information with designated parties.

Parents of students under 18 may submit this form.

STUDENTS OVER 18 MUST FILL OUT THIS FORM THEMSELVES.

Student Name*

First NameLast Name

Student Date of Birth*

MonthDayYear

Is student over 18?*

YesNo

Student Email*

Parent/Guardian Name

First NameLast Name

Parent/Guardian Email

I Hereby Authorize New Way Academy to Exchange Information With The Following:

Name(s)*

Phone Number

Please enter a valid phone number.

Agency Name (If Applicable)

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

The Information To Be Disclosed Is: (check all that apply)*

Verbal/written summary of educational/support services/and interventions including (intervention plans, individualized education plans; educational, behavioral, emotional assessments; psychological, speech and language, and occupational therapy evaluations)Reciprocal verbal communicationWithdrawal/Admission recommendation

If you are a Prospective Student, please choose "Admissions".

If a Current New Way Student, please choose "Staff" and select the name of who is requesting Release of Information.

Was this Requested by Admissions or Staff Member?*

Staff Member:

The Purpose of this Disclosure is:

You may type in a more specific purpose if needed

This Consent is Effective on:*

MonthDayYear

This Consent Expires on:

MonthDayYear

I understand that I may revoke this consent at any time by giving written notice to the person or organization making this disclosure.

NOTICE: This information has been disclosed from confidential records. Any further disclosure without the specific written consent of the person to whom it pertains exceeds the limits of this release. (However, there are legal and ethical requirements that counselors take responsible action in those situations as prescribed by law 1) where there is danger of imminent harm to self or others, and 2) in the case of apparent child abuse.)

Draw your signature into the box below.

Signature*

I understand this is a legal representation of my signature.

Date*

MonthDayYear