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Authorization for Mutual Exchange of Confidential Information

Authorization for Mutual Exchange of Confidential Information

Student Name (Last, First, Middle Initial)

Answer required for "Student Name (Last, First, Middle Initial)"

Student Date of Birth

Answer required for "Student Date of Birth"

Student School and Grade Level

Answer required for "Student School and Grade Level"

I hereby authorize the mutual exchange of any educational, psychological or medical information regarding the abovve named child between the Centralia School District and (list all schools, physicians, psychologists, hospitals, clinics, etc. that have had significant contact with your child.)

Name, Address, Phone Number

Answer required for "Name, Address, Phone Number"

I have been notified of the right to inspect the records, request a copy of the records at my expense, and to have a conference to remove or correct any information that is inaccurate, misleading, or otherwise violates the student's right to privacy, or other rights.

Information sent or received by the Centralia School District may not be shared with any other party without the written consent of the parents or guardians, or the student, if eighteen (18)y years old or older.

Reason for Request:

Answer required for "Reason for Request:"

Name of Person Making Request

Answer required for "Name of Person Making Request"

Relationship to Student

Answer required for "Relationship to Student"

Signature of Person Making Request*

Signature Required

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"