Disclosure Form- Jodi

This disclosure document serves as consent for exchange of information regarding a student with whom I am working. This authorization shall remain in effect until the termination of services by either Jodi Walder (College Admission Coach, LLC) or the person who has signed below. A photocopy or facsimile of this authorization shall be as valid as the original. I welcome an exchange of information regarding any college planning and academic issues and in general an open, collegial relationship that would benefit the student. If you have any questions, please feel free to contact me via phone, e-mail or fax. I look forward to working with you.

Jodi Walder, 503.720.7114 jodi@collegeadmissioncoach.com
Consent for Exchange of Information
Student Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
School*
Graduation Year*
School Counselor*

First NameLast Name
School Counselor Email*
School Counselor Phone Number*

Area CodePhone Number
School District*
Test Prep Provider

First NameLast Name
Test Prep Provider email
Test Prep Provider phone

Area CodePhone Number
Tutor

First NameLast Name
Tutor Email
example@example.com
Tutor Phone

Area CodePhone Number
Therapist

First NameLast Name
Therapist Email
example@example.com
Therapist Phone

Area CodePhone Number
I hereby authorize the exchange of information regarding the above named student between Jodi Walder, College Admissions Coach LLC and and the staff of the above mentioned school district and/or educational professional for the purpose of educational coordination.
Student Signature*

Clear
Parent/Guardian Signature*

Clear
Relationship to Student*
Should be Empty:

Consent for Exchange of Information