STUDENT INFORMATION
School District
*
School Name
*
Student Name
*
First Name
Middle Initial
Last Name
Student ID (if Known)
Date of Birth
*
-
Month
-
Day
Year
Date
Is the student enrolled with a Federally Recognized Tribe?
*
No
Yes, please list
Gender
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Primary Parent/Guardian Information
Primary Parent/Guardian Name (person completing this form)
First Name
Last Name
Email
example@example.com
Phone
Format: (000) 000-0000.
Alternate Parent/Guardian Information
Parent/Guardian Full Name
First Name
Last Name
Email
example@example.com
Phone
Format: (000) 000-0000.
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PURPOSE OF THIS AUTHORIZATION
I authorize the School and/or District listed above to disclose personally identifiable information from the student's education records to Kno'Qoti Native Wellness, Inc. (KNWI), and I authorize KNWI to exchange information with the School/District for the purpose of supporting the student's educational success, wellness, cultural support, and overall stability.
RELEASED INFORMATION
Information you allow the School to share with KNWI (check all that apply)
*
Attendance Records
Discipline records & behavior documentation
SST/MTSS notes and plans
IEP & related documents (if applicable)
Grades/progress reports
Teacher observations relevant to support planning
Section 504 plan documents
Health/wellness info maintained by school
Other
Purpose of disclosure/communication (check all that apply):
*
Student advocacy & support planning
Attendance support & re-engagement planning
Academic support planning
Behavioral health/wellness support coordination
Safety Planning/crisis response coordination
Student Study Team (SST), MTSS, 504 planning
Special Education/IEP support (if applicable)
Other
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AUTHORIZED KNWI STAFF
Primary KNWI Staff Member
Email
example@example.com
Phone
Format: (000) 000-0000.
Alternate KNWI Staff Member
Email
example@example.com
Phone
Format: (000) 000-0000.
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REDISCLOSURE
I understand that KNWI will not redisclose information received from the School/District except as authorized by this consent or as required by law. I understand the School/District may notify KNWI that redisclosure of education records is prohibited without my written consent.
EXPIRATION AND REVOCATION
I may revoke this authorization at any time by submitting written notice to both the School/District and KNWI. Revocation is not retroactive and does not apply to disclosures already made.
This authorization expires on (check or enter one)
One year from the date of signature
When services with KNWI end
On this specific date
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Consent
Parent/Guardian Signature (person completing this form)
Date Signed
*
-
Month
-
Day
Year
Date
Section to be completed by students over the age of 18
Your Name
First Name
Last Name
Student Signature (if age 18+ or eligible student)
Date Signed
-
Month
-
Day
Year
Date
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