St. George Municipal School Unit

P.O. Box 153, Tenants Harbor, ME  04860

Tel.  (207)372-6312, Fax (207)372-6900

Authorization for Release of Information

2018/2019 School Year


I, _________________________________request and authorize St. George MSU to release to, obtain from, and/or discuss with

            (Parent/Guardian Name)


____________________________________information regarding__________________________________________________

            (High School /School District)                                                                    (Student Name and Date of Birth)


This information may include progress notes and grades/report cards.        


This information will be used to help St. George MSU assist St. George resident students in their transition to high school and ensure that they remain connected to and supported by the St. George school community.



NOTE:  This release is valid only for the purpose stated.  St. George MSU must obtain my written authorization before releasing any further information to any other agency.


I do hereby release St. George MSU and ______________________________ from  all liability and all claims pertaining to the

                                                                                            (High School)

disclosure of this information when used as authorized.






____________________________________________________________                                 _________________________

Signature of parent, guardian                                                                                                               Date