Consent to use Personal Information and Request Student Records

Form Title

PARENTAL CONSENT

In accordance with the Freedom of Information and Privacy Act, CHEK ABC requires consent to use personal information for purposes related to educational programs.

I/We give CHEK ABC personnel permission to request the student records including Report Cards, IEP’s and Confidential Red Files (Assessments, Psychology reports, Confidential Red Files, IEP, and Doctors Reports, report cards, etc.) and request records and information from pertinent professionals and organizations.

Sharing of relevant confidential information may be undertaken for the purpose(s) of improving educational programming, helping to provide appropriate school based planning, and obtaining community-based services for your child. I understand the reason for and nature of the confidential information to be shared.

Student's Name(Required)

Grade Level(Required)

Date of Birth(Required)

Signature(Required)

By signing your signature below, you acknowledge that it will serve as your legal signature, authorizing the release of confidential information.

Date Signed(Required)

Previous School Information

School Name(Required)

City / Province(Required)

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School use only:

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Date Requested

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Files received