**SEARHC requires a specific Release of Information form to release & exchange information to Head Start. If you
are a SEARHC client, please complete a Head Start & SEARHC form in addition to this ROI form. **
ERSEA (Enrollment)
REQUEST TO RELEASE & EXCHANGE INFORMATION
AND NOTICE OF CONFIDENTIALITY
Dear Parents/Guardians:
To provide your family with quality services, it may be necessary to release and exchange information with others
that serve your family and child. For example, to review your child’s eligibility, Head Start will need income
statements from ATAP or TANF. Other examples are to allow Head Start to send immunization records to your
child’s local school when he/she transitions to kindergarten, or request current immunization, physical or dental
exam records from your child’s health care providers. Your written consent is required to legally release and
exchange information. This Request to Release & Exchange Information form allows us to share this information
between programs/agencies.
All information gathered is kept confidential and released only when your permission is given. Parents and legal
guardians of Head Start children have the right to access their child(ren)’s files at the Head Start center as well as at
the Head Start Central Office located in Juneau, Alaska.
Child’s First & Last Name:
To rush your application please provide:
Alaska Temporary Assistance Program (ATAP) Benefits-Case Worker: ________________________________
Temporary Assistance for Needy Families (TANF) Case Worker: _____________________________________
Supplemental Security Insurance (SSI) Benefits-Case#: _____________________________________________
State Disabilities Assistance Benefits-Case#: ______________________________________________________
Foster Care – Health & Social Services: __________________________________________________________
Guardianship – Alaska Legal Services: __________________________________________________________
Parent/Guardian Signature Printed Name Date
ERSEA ROI Rev. 04/26/2020
I request the following information for me or my child to be released and exchanged between
Tlingit & Haida Head Start:
Provide Clinic Names (required):
Dental Records / Name of Clinic: _______________________________________________________________
Medical Records & WIC / Name of Clinic: _______________________________________________________
Immunization & TB Test Records/Name of Clinic: _________________________________________________
Please fill out if you receive these services for your child - Name of Agency (required):
Infant Learning Program (ILP) / or Other Program: _________________________________________________
Developmental Screening and Assessment Information at: ___________________________________________
Individualized Education Program (IEP or IFSP) from Local Education Agency (LEA) ____________________
Behavioral or Social/Emotional Service Agency: __________________________________________________
Individual Learning Plan (ILP) Records from another Pre-K Program: __________________________________
Other (records created during Child Find, Tots Clinic, etc.): __________________________________________
THIS RELEASE & EXCHANGE OF INFORMATION IS VALID FOR 12 MONTHS FROM DATE SIGNED.
