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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION

Polk School District

P.O. Box 128

Cedartown, Ga 30125

770-684-8718

Fax: 770-684-3221

 

Student’s Full Name: __________________________      Date of birth:  ______________

Parent/Legal Guardian: ___________________________ Relationship: _______________

Address: __________________________________________________ Home Phone: _______________

Special Education Records to be released:

? All data for Appropriate Educational Placement          ? Medical and Social History

? Educational Screening                                                              ? Psychological/Intellectual Report

? Eligibility Report                                                                         ? Individual Educational Program (IEP)

? Other Information: ____________________________________________________________

I hereby authorize you to release all confidential, psychological, special education and due process records. This information will be used in the placement and planning of my child’s education program. Granting this consent is voluntary on my part. It is understood that the party receiving this information will not release it to a third party without my written consent. It is understood that I may request and receive a copy of all transmitted records. I understand and agree to the above statement.

___________________________________              _____________________________________________

                                Date                                                                      Signature of Parent/Legal Guardian

RECORDS REQUESTED FROM:

SEND RECORDS TO:

 

 

Addressee/Name

 

 

Street

 

City, State, Zip

 

Phone:

 

Fax:  

 

 

 

________________________________________   _______________________________________                     Date                                                                                     Signature of Parent/Legal Guardian

Contact Us
Polk School District 612 South College St.
Cedartown, GA 30125
View Map & Directions
Phone: 770-748-3821
Fax: 770-748-5131
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