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PPP8tuwwwwwwF!h#w111w1u1u: D5P|} Q$0Rd$5d$d$dT|aww5X1111 D  Chandler Unified School District 1525 West Frye Road, Chandler, Arizona 85224 (480-812-7000) Authorization to Request / Release Student Records / Information To/Agency/School: ______________________________ Date:______________ You are hereby authorized to release student records/information on the following child: ______________________________ ______________ ___________________ Last First Middle Birthdate School Attended These records/information may be forwarded to: __________________________________ _______________________________ Name of Person Name of Person __________________________________ _______________________________ Agency Agency __________________________________ _______________________________ Street Street __________________________________ _______________________________ City, State, Zip Code City, State, Zip Code Type of records/information to be released: Reason for request/release: ___Psychological data ___Educational planning and/or placement ___Educational evaluations ___Medical problems relating to learning ___IEPs ___Proof of disability ___Medical records ___Maintenance of student records ___Other ___________________ ___Other _______________________ I understand and give permission for the Chandler Unified School District to request records/information for my child and for sending agency/school to release these records/information. I understand authorizing the request/release of the information identified above is voluntary. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Chandler Unified School District. I understand that the revocation will not apply to information that has already been released in response to this authorization. Photocopies of this authorization are to be given the same effect as the original. ______________________________ _________________________________ Signature of Parent/Guardian Relationship to Student Date Law 815-828 - Not withstanding any financial debt owed by the pupil, any school requested to forward a copy of a transferring pupils record to the new school shall comply and forward the record within five school days after the receipt of the request. New Federal Law 99.31 - No parent or signature required for educational records sent to another educational agency.      FILENAME \p F:\USERS\STEWARTK\4. 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A A B B D E G H J K 2ZX:rV Zhhh^h`OJQJo(hHh88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHTT^T`OJQJo(hH ^`hH. pp^p`hH. @ @ ^@ `hH. ^`hH. ^`hH. ^`hH. ^`hH. PP^P`hH.X:rl  X:r2Z50Ѭ0R+$00                   >B00*[9](>gKK)T\;Z}c@joqxl(eD[^f, 5<+_ @ @@UnknownGz Times New Roman5Symbol3& z ArialA& Arial Narrow?5 z Courier New;Wingdings"1(h9FFafl l !`49 9 2QHP?<+2 Chandler Unified School DistrictInformation SystemsInformation Systems  Oh+'0  8D d p | $Chandler Unified School DistrictInformation SystemsNormalInformation Systems6Microsoft Office Word@G@]c@DC@ l ՜.+,0( hp  $Chandler Unified School District9  !Chandler Unified School District Title  !"#$%&'()*+,-/012345789:;<=@Root Entry F9BData 1Tablex$WordDocument8$SummaryInformation(.DocumentSummaryInformation86CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q