* Required

CONSENT FORM FOR MUTUAL EXCHANGE OF INFORMATION REGISTERED WITH ANSONIA

I hereby authorize the mutual exchange of regular and special education (if the student has been identified as a special education student, please include current IEP and evaluations) records regarding the above-named child between this school district and (list schools, physicians, psychologists, hospitals clinics, etc., that have had significant contact with your child). The purpose of this exchange is to assist educational planning, evaluation and/or intervention.

Student First Namerequired

Student Last Namerequired

Date of Birthrequired (mm/dd/yyyy)

Please provide any recent schools the child has attended (include name and address):

Please enter any physicians, psychologists, hospitals, clinics, etc. that apply (please include the name and address):

I CERTIFY THAT I AM THE PARENT OF LEGAL GUARDIAN OF THE ABOVE-NAMED CHILD OR THAT I AM THE STUDENT OF MAJORITY AGE AND HAVE THE AUTHORITY TO SIGN THIS RELEASE

Electronic Signature:required

Please send a confirmation email to the address below: