Parent Permission to Obtain or Release Information
To obtain or release information about your child, please complete and return one copy using the enclosed self-addressed, stamped envelope, and keep the other copy for your records. If you have any questions, feel free to contact the district office at (920) 788-7605.
Per LCASD policy, the district requires its own release of information form before sharing any information regarding your child.
I, the undersigned, hereby request and authorize_______________________________________________
(school, agency(s), or person)
to release to __________________________________________________________________________________
(school, agency(s), or person)
the information that I have indicated below:
Student Name: __________________________________ Birthdate:___________________________________
- Official student academic/administrative records (identifying information, grade level completed, grades, class rank, attendance records, and group aptitude and achievement tests results)
- Medical and/or related health records.
- Psychological evaluations or social work reports
- Multi-disciplinary team evaluations and related reports
- Appropriate agency reports
- Individualized education program
- Others (specify):
This permission is valid for one year from the date signed. A copy of this form is as effective as the original.
This information is requested for the purpose of: ________________________________________________
____________________________________________ ________________________________________________
Signature of Parent or Legal Guardian (Date)
