REQUEST FOR RELEASE FOR SUPPORT Under 18

We understand it takes a village to raise a child and often time’s children have multiple people on their support team. However, we are not permitted to discuss or release student’s personal information with anyone other than parent or guardian. This form is provided for the purpose of giving The Academy for Urban Scholars staff; consent to speak with someone other than a parent or guardian about their student’s school matters.

  • This form is only valid for the current school year and must be updated annually
  • Parent/Guardian can remove support person at anytime
  • At no time will support person be permitted to make decisions on behalf of the parent/guardian 

By signing this release, you grant consent and permission for school staff to discuss the below with the person identified on this form.  Staff must witness parent/guardian sign this form.

  • Attendance
  • Copy of Student’s Data Form
  • Grade Card (or information about pupil placement)
  • Individual Education Plan
  • Behavior
  • Discipline
  • ALL test information / results
  • Intervention
  • Evaluation
I hereby give permission for The Academy for Urban Scholars staff to speak with:
Student Signature *
clear
 +

Received by: _________________________    ____________________________

                                (Print Staff Name)                        (Staff Signature)

1808 E. Broad St. ♦ Columbus, Ohio 43203  ♦ Phone: 614-545-9890  ♦ Fax: 614-545-9889

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