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STAMFORD PUBLIC SCHOOLS CONSENT FOR RELEASE/EXCHANGE OF INFORMATION

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STAMFORD PUBLIC SCHOOLS
CONSENT FOR RELEASE/EXCHANGE OF INFORMATION
I, _____________________________________, give consent to Stamford Public Schools, to release information
to and obtain information from____________________________________________________________, in regard
to (child’s name)__________________________________________________, D.O.B.______________________.
The above-named agency or individual provider’s address is ____________________________________________
___________________________________, and contact information is ___________________________________
Type of Information
Medical
Psychiatric/Mental Health
Academic
Behavioral
Other (specify):___________________________________________________________________
THE PURPOSE FOR REQUESTING THIS INFORMATION IS:
____________________________________________________________________________________________
Date of expiration for this consent: one year from date of parent signature.
I understand that I may revoke this consent at any time by notifying Stamford Public Schools in writing. Any
information gathered or released prior to the revocation of this consent is valid and cannot be voided. I also
understand that, even if I do not revoke this consent, the consent will expire at the end of the year.
________________________________________ ________________________________________
Signature of Guardian Signature of School Personnel
________________________________________ ________________________________________
Relationship to Child Title
________________________________________ ________________________________________
Date Date
________________________________________
Stamford Public Schools Contact Name
________________________________________
Stamford Public Schools Contact Title and Date
SR-7 Revised September 2013
SR-7
CONSENT FOR RELEASE/EXCHANGE OF INFORMATION
1. This form should be filled out:
a. Whenever a student withdraws from a school or program Form SR-7 must be given to the parent or legal
guardian.
b. When any information identifiable to a particular student is requested by an agency outside the Stamford Public
School system, Form SR-7 must be completed.
c. When parents request copies of records for themselves or outside agencies.
2. Form SR-7 can only be completed by the student over 18, the parent or legal guardian.
3. The original is to be placed in the student’s cumulative folder for non-handicapped students.
4. The original is to be placed in the student’s PPT folder for handicapped students.
5. A copy of completed Form SR-7 is to be given or sent to parent.
6. A copy of completed Form SR-7 is to accompany the record to the agency.
7. The name of the staff member in whose presence Form SR-7 is completed — or receiving the completed Form SR-7 – is
to be recorded before any record is released.
8. The release must be recorded on Form SR-9, Log of Access.
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STAMFORD PUBLIC SCHOOLS CONSENT FOR RELEASEEXCHANGE OF INFORMATION

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Completed 13 September 2021

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