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Release of Confidential Health/Educational Information

This form authorizes the reciprocal disclosure of confidential health/educational records between our program and your child's current providers of health/educational care pursuant to the rules and regulations of the Family Educational Rights and Privacy Act (FERPA). This information may be redisclosed between the parties and providers in support of the indicated child's educational programming pursuant to FERPA. You have the right to revoke this authorization at any time by writing to the CPSE Office of Liverpool Central School District and requesting such action.

Child's Last Name:*

First Name:*

DOB:*

Name and Address of Agency/Site disclosing information:

Any approved county or district agency/site providing special education services listed below

•Childtime Learning Center #0041 7453 Morgan Road Liverpool, NY 13090 315-451-5246

•County North Children's Center, Inc. 205 School Road Liverpool, NY 13088 315-451-8520

•Northminster Early Childhood Center 7444 Buckley Road North Syracuse, NY 13212 315-458-2669, option 2

•PEACE lnc./Head Start 911 Old Liverpool Road Liverpool, NY 13088 315-451-9377

•Shining Stars Daycare, Inc 120 Metropolitan Park Drive Liverpool, NY 13088 315-457-4500

•True North Center for Children 4431 Waterhouse Road Clay, NY 13041 315-652-7896

Onondaga County Approved Agencies and SCIS Providers

•Building Blocks 19 Robinson Rd Clinton, NY 13323 315-853-6090, ext 387

•Children's Therapy Network Intrepid Lane Syracuse, NY 13205 315-437-4689, 315-437-4690

•Elmcrest Early Education Center- SPICE & Small Wonders 960 Salt Springs Rd Syracuse, NY 13224315-446-3220 ext 367

•Gebbie Speech/Language Hearing Clinics Syracuse University 621 Skytop Road, Suite 1200 Syracuse, NY 13210315-443-4485

•Jowonio 3049 East Genesee Street Syracuse, New York 13224 315-445-4010

•Liberty Resources POST 6723 Towpath Road East Syracuse, NY 13057 315-440-6514

•Little Lukes (Radisson and Dewitt locations) 159 West First Street Oswego, NY 13126 315-207-2027

•Milestones/315 Therapy 159 West First Street Oswego, New York 13126 315-342-9575 (ext 4)

•North Syracuse Early Education Program 205 South Main Street North Syracuse, New York 13212 315-218-2200

•Sprout Therapy Group 115 Continuum Drive Suite 1A Liverpool, NY 13088315-450-4898

•Golisano Center for Special Needs SUNY Health Science Center at Syracuse, Upstate Medical University 475 Irving Ave, Syracuse, NY 13210 315-464-3555

•Thrive By 5 605 Bailey Road North Syracuse, NY 13212 315-218-7444

Other person/agency (Please include name, address and phone number)

Name of Person Completing Form:

Relationship to child:

Address of Person Completing Form:

Name: Liverpool Central School District Address: 195 Blackberry Road Fax Number: 315-622-7166 Liverpool, NY 13209

Phone Number: 315-622-7161 Fax Number: 315-622-7166

Person/Facility Requesting Information:

All educational records
Reports of any diagnostic screenings, tests, treatments, or recommendations
Prescription for Services
Exchange of Information
Other:

Information requested for the purpose of coordination of care:

Print Break

Unless otherwise revoked, this authorization for the release of information is valid for one year from the date signed.

Parent/Guardian Signature*

Date*

Liverpool EPK Sites