I, _______________________________(Parent/Guardian), do hereby authorize

Name ____________________________

Address ____________________________

____________________________

Phone ____________________________

to release medical, social, and academic information about

_______________________________(Student Name), born _______________________________(M/D/Y)

I also give my authorization for the Rydell City Schools to release medical , social, and academic information requested by physicians, agencies, school, and institutions for the purpose of improving the physical/academic well being of the above named child. I understand that the Rydell City Schools will not disclose or disseminate information created or received about my child except for the purposes of appropriate medical treatment, social and/or academic assessment. All information received by the Rydell City Schools will be shared with social workers, nurses, principals, teachers, counselors, and psychologists only as necessary.

I understand this authorization is for the school year 2020-2021. 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 information received before the revocation.