esignature | atrr


AUTHORIZATION TO RELEASE RECORDS

 

You can also download the SJB Authorization to Release Records Form here, and mail or deliver it to St. John the Baptist.

Additionally, you can email your completed document to Lucero Silva at lsilva@sjbcatholicschool.org.

 

 

 

Student Name:  

Date of Birth:  

 

To (Medical or Professional Provider):

Address:  

Phone #:    Fax #:  

 

As parent/guardian of above named minor child, I authorize the release and exchange of confidential educational materials, medical records, diagnoses, psychological evaluations, special education records and other information between and St. John the Baptist School to be used to support my student’s educational needs. I also give permission for verbal exchange of information.

 

I hereby approve the release of information as indicated above. A copy of this authorization shall be deemed as original. I may revoke this authorization in writing at any time. Such revocation may not be retroactive.

 

 

Printed Name of Parent or Guardian:    Relationship:  

 

Signature of Parent/Guardian:    Date:

 

 

Please send information to: SJB

Attn: Lucero Silva

10956 SE 25th Ave

Milwaukie, OR 97222

Tel: 503-654-0200 Fax: 503-654-8419

Leave this empty:

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Document name: esignature | atrr
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Timestamp Audit
July 7, 2020 7:29 pm PDTesignature | atrr Uploaded by Lucero Silva - lsilva@sjbcatholicschool.org IP 24.20.22.127