PARENT PERMISSION TO OBTAIN AND RELEASE INFORMATION OUTSIDE AGENCIES
Date:
Student Name:
Last First MI
Address:
Street/PO Box City State Zip Code Home Telephone #
Tribal Information: _____________________________________________________________________
Tribal Affiliation Tribal Enrollment #
I, the undersigned, hereby request and authorize:
AND Ho-Chunk Nation Disabilities Program
Attn.: Cheryl Funmaker
P.O. Box 667
Black River Falls, WI 54615
School District Name:
Office:
Street Address:
City, State, Zip:
To exchange requested information pertaining to the student named above which has been indicated below:
Official Student academic/administrative records (identifying information, grade level completed, grades, class rank,
attendance records, and group aptitude and achievement test results)
Medical and/or related health records
Psychological evaluations or social work reports
Individualized education team evaluations and related reports
Appropriate agency reports
Individualized education program (IEP)
Other (specify):
This permission is valid for one year from the date signed. A copy of this form is as effective as the original.
NOTE: Ho-Chunk Nation Department of Education reserves the right to information gathered during this period.
HCN Education Department
Phone: (715)284-4915 * Fax: (715) 284-1760 * Email: Education.Intake@Ho-Chunk.com
Parent / Guardian
Signature: Date:
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