Chandler Unified School District



Chandler Unified School District

1525 West Frye Road, Chandler, Arizona 85224

(480-812-7000)

|Authorization to Request / Release Student Records / Information |

To/Agency/School: ______________________________ Date:______________

You are hereby authorized to release student records/information on the following child:

______________________________ ______________ ___________________

Last First Middle Birthdate School Attended

These records/information may be forwarded to:

__________________________________ _______________________________

Name of Person Name of Person

__________________________________ _______________________________

Agency Agency

__________________________________ _______________________________

Street Street

__________________________________ _______________________________

City, State, Zip Code City, State, Zip Code

Type of records/information to be released: Reason for request/release:

___Psychological data ___Educational planning and/or placement

___Educational evaluations ___Medical problems relating to learning

___IEP’s ___Proof of disability

___Medical records ___Maintenance of student records

___Other ___________________ ___Other _______________________

I understand and give permission for the Chandler Unified School District to request records/information for my child and for sending agency/school to release these records/information. I understand authorizing the request/release of the information identified above is voluntary. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Chandler Unified School District. I understand that the revocation will not apply to information that has already been released in response to this authorization. Photocopies of this authorization are to be given the same effect as the original.

______________________________ _________________________________

Signature of Parent/Guardian Relationship to Student Date

• Law 815-828 - Not withstanding any financial debt owed by the pupil, any school requested to forward a copy of a transferring pupil’s record to the new school shall comply and forward the record within five school days after the receipt of the request.

• New Federal Law 99.31 - No parent or signature required for educational records sent to another educational agency.

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