Authorization for Release of Information
Wayzata Public Schools, ISD284
Student's Name
*
First Name
Last Name
Student's Date of Birth
*
-
Month
-
Day
Year
Date
Student's Grade
*
Please Select
9
10
11
12
Student's ID Number
Student's School
*
Please Select
Wayzata High School
Student's Counselor or Social Worker
*
Please Select
Alison McKernan (A-FJ)
Jennifer Ruprecht (FL-LAQ)
Cali Fielder (LAR-RA)
Jodi Sorenson (RB-Z)
Julie Sailors (Special Services)
Peggy Zimmer (U-Z)
Parent/Guardian or Legal Representative Name
*
First Name
Last Name
Parent/Guardian or Legal Representative Phone Number
*
Please enter a valid phone number.
Parent/Guardian or Legal Representative Email Address
*
example@example.com
I, named above, authorize Wayzata Public Schools, ISD 284,
*
to release the specific information identified below to:
to obtain specific information identified below from:
Name of individual or entity:
*
Provider Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Release of:
*
health records
medical reports
chemical abuse / dependency report
psychological reports
psychiatric report
teacher, counselor, staff observations
special education records
social work report
Other
For the purpose of:
*
I understand that this authorization takes effect the day I sign it, cannot exceed one year, and expires on:
*
-
Month
-
Day
Year
Date
I further understand:
I may refuse to sign this authorization and it will not affect my child’s ability to receive educational services,
the laws that protect the information identified on this release, in some situations, may allow or require this entity to re-disclose this information, but only as permitted by law (Health Insurance Portability and Accountability Act [HIPAA], Family Educational Rights and Privacy Act [FERPA], Minnesota Government Data Practices Act [MGDPA or Chapter 13]),
a digital version of this release form is as valid as an original, and
I will receive a copy of this authorization.
Signature
*
Submit
Should be Empty: