I, _______________________________(Parent/Guardian), do hereby give my permission and consent for

Name ____________________________

Address ____________________________

____________________________

Phone ____________________________

to release information for the purpose of meeting my family’s needs. I understand that Rydell City Schools will not disclose or disseminate information created or received about me except for purposes of appropriate assistance as it relates to me or my family. All information received by Rydell City Schools will be shared with social workers, only as necessary.

I understand that I may revoke this authorization at any time by notifying the Rydell City Schools in writing, but it will not have any effect on any information received before the revocation.