Authorization for Release and Exchange of Information
I, (print name of adult below), declare that I am the parent/legal guardian of (print name of student below), and that my child will receive or is receiving services through (print name of organization below).
1. I authorize San Francisco Unified School District to release information from my child's
educational record to the organization named above. The information can include:
>> My child's name, address, phone number and emergency contact information
>> Name of school and grade level
>> Daily school attendance information
>> Grades and Report Cards
The information disclosed to the organization will be used for the following purposes:
>> Assist the program in assessing my child in order to provide him/her with appropriate services
>> Assist the program in providing case management for my child
>> Track my child's progress and provide information for the evaluation of the effectiveness of the program
2. I request the following exceptions to
this authorization: ____________________________________
3. I understand that I am entitled to receive a
copy of this signed authorization form and that this
authorization can be revoked at any time, if done in writing.
By submitting the form below, I agree to the SFUSD Authorization terms listed above