Authorization For Release Of Information

Student Information:

Student’s Full Name: Date:
Date Of Birth: Grade Entering:
Phone: Email:

School Information:

Name of School, Service Provider or Evaluator:
Phone: Fax:

Please check all the information requested:
Complete Education File
Special Education Files (If applicable)
Permission to make/receive phone calls from above listed professional
Other (Please specify)

Please specify additional information:

In order to assist in the provision of an appropriate education program for my Child, and in accordance with the Family Educational Rights and Privacy Act of 1974 and Arizona State Law, I hereby authorize the release to Desert Garden Montessori any student records, including grades, health records, as well as psychological, social, educational, developmental, etc., for the above student.

By typing my name below, I agree to conduct business with Desert Garden Montessori by electronic means. I intend, by typing my name below, to “sign” the preceding document and to be bound by its terms and conditions.

Parent Signature: Date:

Please send all school records to:

Desert Garden Montessori
5130 E. Warner Road
Phoenix, AZ 85044
Phone: 480-496-9833
Fax: 480-705-8579
Attention: Karen Hurlbert