PERMISSION TO OBTAIN OR RELEASE RECORDS AND INFORMATION
I give permission for _____________________________________________ to release and / or
Name of school obtain information on my child, ___________________________________________, whose first middle initial last date of birth is ________________________________________ from/ to the following school,
month day year agency, or person(s):
1 .
Name of School, Agency or Person(s):
2. Records to be released / obtained:

Academic Records

EST notes

IEP evaluation

Behavioral checklists

Previous comprehensive evaluations

Other
3. The purpose(s) of the disclosure is / are:
_______________________________________________________
Printed name
__________________________________________________________ _________________
Signature Date

If the dominant language of the home is other than English, this form must be completed in that language as well as in English.

Parent(s) may review the files upon request.

Parent(s) may have copies upon request.
For questions please call: _______ ____________ _ _______________________ _________________
Name tel.#
Product of the VCHIP ADHD Practice Improvement Projects, 2008.