Consent for Mutual Exchange of Information

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 Namerequired
First Name
Middle (optional)
Last Name
(mm/dd/yyyy)
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 AGREEMENT: BY TYPING YOUR NAME IN THE BOX BELOW AND CLICKING THE "SUBMIT" BUTTON, YOU ARE SIGNING THIS AGREEMENT ELECTRONICALLY. YOU AGREE YOUR ELECTRONIC SIGNATURE IS HE LEGAL EQUIVALENT OF YOU MANUAL SIGNATURE ON THIS AGREEMENT. WHEN PRESSING "SUBMIT" YOU CONSENT TO BE LEGALLY BOUND BY THIS AGREEMENT'S TERMS AND CONDITIONS.
Electronic Signaturerequired