To download a copy of our “School Release of Information Form” in a Microsoft Word document (.doc) version, simply click here. The form will automatically download to your device or computer.
Please return your completed form by email to laurie@specialeducationguru.com
School Release of Information Form
Consent to Communication and Disclosure of School Student Records
Student Name: _________________________
Date of Birth: __________________
I give my consent for ______________________________________
(Name of educational Institution, Therapist, etc)
to disclose and communicate regarding any and all of the information set forth below to Dr. Laurie Hoke, Educational Concierge
Information to be disclosed to recipient:
The complete student record of ____________________________,
(Student Name)
(Please check all that apply)
Report Card ___
MTSS Forms ___
Case Study Evaluation ___
Eligibility/IEP Paperwork ___
504 Paperwork ___
Discipline Records ___
Other__________________
Permission for the aforementioned to speak to:
(Please check all that apply)
School Counselor/Social worker ___
School Psychologist ___
Teachers ___
Private Therapist ___
Private Tutor ___
Other__________
This consent is valid for one calendar year from the date set forth below, and may be revoked at any time in writing. I also understand that I have the right to inspect and copy the information to be disclosed pursuant to this consent.
Parent/Guardian’s Signature: _____________________
Witness: _________________________
Date: ___________________________
Student’s Signature: __________________________
Date: ___________________________
Note: If the student is under age 12, only the parent’s signature is needed. If the student is between ages 12 and 18, both the parent’s and student’s signature are needed. If the student is age 18 or over, only the student’s (or if the student has been judged to be incapacitated by a court, the guardian’s) signature is required.