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RELEASE OF RECORDS
Brooklyn Elementary School
119 Gorman Road
Brooklyn, CT 06234
Phone: 860-774-7577
Fax: 860-779-1162
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STUDENT NAME:
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Your answer
DATE OF BIRTH:
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MM
/
DD
/
YYYY
In regards to the above child, I hereby authorize The Brooklyn School to do the following with my student´s records:
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Release
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In regards to the above child, I hereby authorize The Brooklyn School to do the following with my student´s records:
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Request
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Please include the following records:
*
Social Work Records
Psychological Records
Speech Evaluations and Reports
Educational Evaluations and Reports
PPT Minutes
Individual Education Plans
Admission Summaries
ISSIS Information
Health Records
Achievement Scores
Anecdotal Information
Academic Records/Grades
Guidance Evaluation Check Sheets and Reports
Psychiatric Report(s)
Discharge Summaries
Other:
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School Transferring From (Name of school, address, phone number, fax number):
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