CRSD Release Form

COUNCIL ROCK SCHOOL DISTRICT

Special Services Department

30 N. Chancellor Street.

Newtown, PA 18940

(215) 944-1000
PARENTAL AUTHORIZATION
Regarding Student:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
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psychological evaluationpsychiatric evaluationsocial work reportsneurological evaluationmedical history/evaluationdischarge summaryhealth recordsschool records: academic records, standardized test data, anecdotal informationtreatment/aftercare planOther
for the purpose of
e.g. School Evaluation, Team Communication
This consent will begin the date of this authorization and will expire one year from submission unless revoked by me in the interim. I, the undersigned, hereby acknowledge that I have read this authorization prior to its execution and fully understand the nature of this release. All information released will be handled confidentially in compliance with the Federal Privacy Act (PL 93-380 Sec. 438) and the Pennsylvania Mental Health Procedures Act, and the Federal Educational Rights Privacy Act or FERPA.

FERPA
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Signature of Student

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Signature of Witness

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Date of Authorization*

MonthDayYear
Date
THIS INFORMATION IS FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED BY FEDERAL LAW. FEDERAL REGULATIONS PROHIBIT MAKING ANY FURTHER DISCLOSURE OF IT WITHOUT THE SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS, OR AS OTHERWISE PERMITTED BY SUCH REGULATIONS (42 CFR Part 2). A GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMATION IS NOT SUFFICIENT.
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PARENTAL AUTHORIZATION