Westbrook School Department 117 Stroudwater Street Westbrook, Maine 04092

AUTHORIZATION FOR RELEASE OF INFORMATION Name of Student: ________________________________________ DOB: ___________________ Name of school requesting information from: ________________________________________________ Address: ________________________________________________ I authorize the above stated school to release the following: Educational records Special Services/504/ESL records Health/Immunization records Transcript

Current Schedule Current Grades w/grades to-date-of leaving Attendance and Behavior records MEDMS # (Maine only)

The purpose of the disclosure authorized herein is to: Transfer Pupil Records Date consent expires: ___________________________________________________________________ Relate length to need. (Maximum is one year for mental health services, six months for children in residential care only and ninety days for one-time disclosures.)

Note: This authorization may be revoked at anytime in writing, subject to the right of any person who acted in reliance on it prior to receiving notice of the revocation.

Yes _______ (Client Initials)

Yes _______

N/A Information may be disclosed about treatment or diagnosis of drug or alcohol abuse. Please note: If this is checked yes, this consent will also need to be signed by the client.

N/A Information may be disclosed about treatment or diagnosis of HIV infection or AIDS.

For the person(s) providing consent: • This consent has been made freely, voluntarily and without coercion. • I herby authorize releasing/obtaining of the information as specified about and understand that any information released may potentially be redisclosed and no longer be protected by Federal Law. • I understand that I may revoke this authorization at any time. • I understand that refusing or revoking consent could result in improper diagnosis or treatment.

Signature of Parent/Guardian:____________________________________ Date: _____________________ Print Name: __________________________________________________ **REVOCATION OF CONSENT** I am revoking this consent to release/disclose information effective as of this date. This revocation does not apply to any actions previously taken in reliance on my consent, including disclosures made or services rendered. Signature_____________________________________ Date___________________

One Promise: The best education for all for life.