Woodland Hills School District

Woodland Hills School District
Special Education Department

531 Jones Avenue, North Braddock, PA 15104  Phone: [phone]  Fax [phone]

CONSENT for RELEASE OF INFORMATION
_________________________ ______________________

(STUDENT) (SCHOOL)



_________________________ ______________________

(BIRTHDATE) (DATE)
FROM: ____________________________________________________________

(SCHOOL-HOSPITAL–PHYSICIAN-AGENCY)

___________________________________________________________
____________________________________________________________
I, _________________________________, authorize the release of any and all information

(Parent/Guardian)

requested from my son/daughter’s records as outlined below:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

(Itemize reports and time period)

Effective through: ______________________________________________________________
To be sent to: ___________________________________________________________________________________
WOODLAND HILLS SCHOOL DISTRICT

Special Education Department

531 Jones Avenue

North Braddock, PA 15104

I understand the information to be sent shall remain confidential and not a part of my child’s academic record.

__________________________________ _____________________________

(Student Signature if over 14 years of age) (Date)

__________________________________ _____________________________

(Parent Signature) (Date)

__________________________________ _____________________________

(Administrator Signature) (Date)

JRJan-16

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