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Release of Information Final

This document is an information release form from Red Lion Area School District authorizing the release of a student's information to various organizations to assist in developing and implementing their educational program. The form provides the student's name, date of birth, address, and school. It allows the release of evaluation reports, medical reports, grades, observations, discipline reports, IEP information, social/family history, attendance, and transition assessments. The parent and student (if over age 14) must sign to authorize the release and can revoke the authorization at any time.

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86 views1 page

Release of Information Final

This document is an information release form from Red Lion Area School District authorizing the release of a student's information to various organizations to assist in developing and implementing their educational program. The form provides the student's name, date of birth, address, and school. It allows the release of evaluation reports, medical reports, grades, observations, discipline reports, IEP information, social/family history, attendance, and transition assessments. The parent and student (if over age 14) must sign to authorize the release and can revoke the authorization at any time.

Uploaded by

api-320878149
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Red Lion Area School District

696 Delta Rd.


Red Lion, PA 17356

INFORMATION RELEASE FORM


I hereby authorize Red Lion Area School District and the following organizations, as marked, to
release and receive information regarding the student named below:
Lincoln Intermediate Unit
Community Care Behavioral Health (CCBH)
York County Office of Children, Youth & Families
York County Early Intervention
York County MH/IDD
York County Drug and Alcohol Program
York County Juvenile Probation

Service Access Management


Guardian Ad Litem
____________________________
____________________________
____________________________
____________________________
____________________________

From the record of:


__________________________________________
NAME

______________________________
DATE OF BIRTH

__________________________________________
ADDRESS

______________________________
SCHOOL

I authorize the release and exchange of the following information for the purpose of collaboration and
to assist in the development and implementation of my childs educational program. Select all that
apply:
Evaluation/Reevaluation Reports
Psychiatric/Neurological Reports
Progress Reports
Grades/Report Cards
Teacher Observations
Behavior/Discipline Reports
IEP/Progress Monitoring

Social History/Family Information


Attendance Information
Transition Assessments
Other pertinent information including
verbal communication
____________________________
____________________________

By my signature below, I certify that I have read this form carefully and understand what it
means. I understand that I may revoke this authorization at any time by verbal or written notice to the
Pupil Personnel Office.
___________________________
Signature of Parent

________
Date

____________________________

_________

Signature of Student (age 14 or above)

Date

In Accordance with Pennsylvania Regulations: This information has been disclosed to you from records whose confidentiality is protected
by State Law. State regulations limit your right to make any further disclosure of this information without prior written consent of the person
to whom it pertains.

{00764955/1}

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