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Jordan-Elbridge Central School District

Central Registration
9 North Chappell St.
Jordan, NY 13080
Phone: 315-689-8500 ext 5011

Secure Fax: 315-689-0084

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize the Jordan-Elbridge Central School District:

To release information to:

To receive information from:

Name of School / Agency / Doctor*

Address of School /Agency / Doctor

Phone Number of School / Agency / Doctor

Regarding (Student Name & DOB)

First Name:*

Last name:*

DOB:*

All educational records to include:

All special education records to include:

Current Report Card/Transcript
Grades at time of withdrawal
Health / Immunization Records
Attendance Records
Discipline Reports
Standardized Test Results
Achievement Test Results
NYS Assessment Results
NYS Regents Competency Results

IEP – Hard Copy
IEP – Transfer via IEP Direct
Psychological Reports
OT Reports
PT Reports
Speech Reports
Visual Reports
Hearing Reports
FBA
BIP

Parent / Legal Guardian Signature (use mouse)

Relationship to Student

Date*

Before submitting this form, please check your answers. Any questions with a red * are required. After submitting the form if you get a validation error, please look for and complete any questions/fields that turn red.