Authorization for School Access and Release of Information

Authorization for School Access and Release of Information

Circle of Friends
Circle of Friends is a community based, child-serving organization that is working with:
Youth's Full Name

First NameLast Name
Youth's First and Last Name
Youth's First and Last Name
As legal guardian, I give permission for Circle of Friends Staff and Volutneers to visit, and pick up from school:
Youth's Full Name

First NameLast Name
I also give Circle of Friends access to any information that Sisters School District may have on my child. This may include but is not limited to: Personally identifiable information, attendance records, test scores, assessments, report cards, referrals, suspensions or expulsions, Individualized Education Plan (IEP) or 504 Plan, and any special notes or evaluations. This information will be used by Circle of Friends and its independent evaluation team to assess the progress of the program. In all cases your child’s identity will remain completely confidential.

We are requesting that this Authorization form remain in the child’s school folder from the date below until his/her High School Graduation. The parent/guardian may rescind this authorization at any time.

I approve the school access and release of information as indicated above. I understand that I may revoke this access and release in writing at any time.
Parent/Guardian Name

First NameLast Name
Signature

Clear
Today's Date

MonthDayYear
Date
Should be Empty: