110 W. Redwing Street
Duluth, MN 55803
218.464.5570
manyriversmontessori.org
Authorization for Release of Information
Child’s current/former school or day care:
Address: ___________________________________ Phone: _____________________________
___________________________________ Fax: _____________________________
___________________________________ Email: _____________________________
Permission is hereby given to Many Rivers Montessori School to receive information from you regarding:
Child’s Name: __________________________________
Address: _________________________________
_________________________________
Reason for Request: _________________________________________________________________
Copy of records to be transferred include:
_______ Official Administrative Records: name, address, birth date
_______ Current Pupil Progress Reports
_______ Standardized Test Data ( as available )
_______ Health & Immunization Records
_______ Psychological Reports
_______________________________________________ _________________________
Parent/Guardian Signature Date
Please Forward Information to: