Student Support Services
2929 McDougall Ave.
Enumclaw, Washington 98022
Authorization for Exchange of Confidential Information
Student’s Name:
Grade:
Date of Birth:
School student is registered at in Enumclaw School District:
I hereby authorize the exchange of confidential information with the agency/person(s) listed below:
To:
Name of School/Agency/Person(s)
Street Address
City, State, Zip
Fax Number
Check all appropriate items:
Health Records
Psychological and Counseling Records
Special Education Records
Transcripts
Other (Specify)
The reason for disclosing the records is to determine appropriate special education placement and services.
I understand that the information obtained will be treated in a confidential manner and will not be
transmitted to a third party without my permission. I also understand that it is my right to request a
copy of all information and contest any information I feel is incorrect.
Parent/Guardian Name (Printed)
Home Phone Number
Parent/Guardian Signature
Work Phone Number
Street Address
City, State, Zip Code
Send Information to:
Date
Director of Student Support Services
Enumclaw School District
2929 McDougall Avenue
Enumclaw, Washington 98022
Phone Number: 360.802.7125
Fax Number: 360.802.7132
Form faxed/mailed by:
Date: