Forsyth County Schools
Forsyth County Schools
Records Release Request
Student Information_________________________________________________________________________
| Name | |Nickname | |Birth Date | |
| Home Phone | | Ethnicity | | | |
| Address | | Gender | |Registered | |
|City, State, Zip | | | |Start Date | |
School / Agency Information___________________________________________________________________
|RELEASING |REQUESTING |
| |Preschool Special Needs |
| |Almon C. Hill Educational Center |
| |136 Almon C. Hill Drive |
| |Cumming, GA 30040 |
| |ATTN: Tracy O’Connor, School Psychologist |
| Phone | Phone 770-887-2461, ext. 312819 |
| Fax | Fax 678-965-5026 or email records (preferred) to |
| |toconnor@forsyth.k12.ga.us |
Type of Material (All Available)_______________________________________________________________
Special Education Record
Psychological Report
Determination of Eligibility (DOE)
IFSP
Therapy Notes/Evaluation
I understand that I may revoke this authorization at any time by submitting written notice of withdrawal of my consent. I recognize that health records once received by local education agency (LEA) may no longer be protected by HIPPA, but they will become educational records protected by the Family Educational Rights and Privacy Act (FERPA).
I hereby authorize the Forsyth County School system to release/obtain pertinent information concerning the above-named student for educational planning/medical treatment or (please specify):
__________________________________________________________________________________________________________________
________________________________________ Date Records Requested _________________________
Initials:_____________
Authorizing Signature Date Records Received ___________________________
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