IDHS: Illinois Department of Human Services
Teen REACH Release of Information
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Teen REACH Parental Consent Form
General Information
Name: ________________________________
Address: _____________________________City:______________________________
State Zip Code: ___________________
Date of Birth: / / Age: SSN (optional): - -
Grade: _______________________
School Name: _________________________________________
Address: ___________________________________
Phone: ___________________________________________
Teacher: _______________________________________ Room Number: ______________
Release of Information:
As the legal parent/guardian of , I authorize the School District and/or the educational institute my child attends to release the following information to this Teen REACH site on a quarterly basis: grade point average, photocopies of report cards, school attendance rates, grade achievement information and graduation information.
Parent/Guardian Signature Date
Home Phone Number: - - Work Number: - -
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