RECORDS TO BE RELEASED TO
DREAM ACADEMY SCHOOLS, 5622 Marine Parkway #9, New Port Richey, Florida 34652
I (PARENT/GUARDIAN), do hereby authorize the release of the following information on the enrolled student listed on the previous pages, from the previously named most recent school.
Entire Cumulative Record Folder (Applicable for student transfer to another school or system) to include:
➤Exceptional Student Education Records ➤Grades at Time of Withdrawal
➤Grading System ➤Record of Achievements, Special Awards/Activities
➤Official School Transcript ➤Psychiatric Evaluation
➤Psychological/Social Work Reports ➤Treatment/Services Plan
➤Medical/Health Records (including speech, language, hearing, vision and immunization records)
AUTHORIZATION FOR EXCHANGE OF INFORMATION/RELEASE OF CLIENT RECORDS
These records will be for the professional use of authorized Dream Academy Schools personnel only. Records will be used for educational planning, placement, and/or evaluations. Parent permission is not required when records are requested from authorized personnel or from officials of schools/school systems in which the student seeks to enroll (Family Educational Rights and Privacy Act of 1974, FERPA). Records information shall not be released except on the condition that they will not subsequently be transferred to a THIRD PARTY without first obtaining the proper consent of the parent or eligible student.
Conditions of this exchange of information shall be in compliance with federal regulations, the Family Educational Rights and Privacy Act of 1974 (FERPA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and all other applicable federal laws, state statutes, State Board of Education Rules, and local School Board policy.
This authorization shall be terminated one year from the date of signature unless otherwise specified. This consent may be revoked by the client/representative at any time. Revocation has no effect on action previously taken.