CONSENT FOR RELEASE
OF INFORMATION
DISTRIBUTION: School Parent Agency eCSSS, OITS-IAS
Form HAR 34
Rev. 11/11, RS 12-0504
STATE OF HAWAI‘I
DEPARTMENT OF EDUCATION
Student’s Name: _______________________________________________________________ Date of Birth: ________________
Grant permission to the Hawai‘i Department of Education, ___________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
To: q RELEASE q RECEIVE (Check one)
the following document(s)/information, on the above named student, except that which is legally not subject
to disclosure by law, and is covered under the Hawai‘i Revised Statutes, §325-101 Infections and Communicable
Diseases (HIV Infection, ARC, and AIDS); §329-68 Uniform Controlled Substances Act (Protection of records;
divulging condential information prohibited) and §329-B6 Substance Abuse Testing (Test Results) to or from the
agency or person listed below:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Specify document(s)/information authorized for release or receipt:
For the purpose of:
This personal document(s)/information will be transmitted to the agency or person named above only on the
condition that it not be shared with another agency or other person(s) without the written consent of the parent(s),
or legal guardian(s), or eligible student (an “eligible student” means a student who has reached 18 years of age or
is attending a postsecondary institution at any age).
_______________________________________________ ______________________________________________
_______________________________________________ ______________________________________________
______________________________________________________________________________________________________
Last Name First Name Middle Initial
Name of DOE School or Ofce
Address City State Zip Code
Department of Education Contact Phone Number Fax Number
Name of Agency or Person Phone Number
Address City State Zip Code
Parent/Legal Guardian or Eligible Student Signature Date
PRINTED Name of Parent/Legal Guardian or Eligible Student Phone Number
Address City State Zip Code
click to sign
signature
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