SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

361/555-1234

SPECIAL EDUCATION

STUDENT RECORD RELEASE AUTHORIZATION

Date: ______________________________________

Student _____________________________ Birthdate ___________ Grade ______________

My child’s previous school, _____________________________________________, has my consent to release the special education information on the above named student to the XYZ Charter School, 719 Fourth Street, Anytown, Texas.

Signature: ___________________________ Relationship to student ____________________

Date Enrolled: _________________________________

Name and address of previous school:

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

NOTE TO SENDING SCHOOL: PLEASE FORWARD CONFIDENTIAL RECORDS TO THE ATTENTION OF THE SCHOOL COUNSELOR AT ABOVE ADDRESS.

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