Lee County Schools

Lee County Schools

P. O. Box 1010

Sanford, NC 27331-1010

919-774-6226

Fax: 919-776-4954

CONSENT FOR RELEASE OF CONFIDENTIAL STUDENT INFORMATION

I hereby authorize and Lee County

Name of Physician/Healthcare Provider/Health-related agency

Schools’ staff to share with each other specific information in the client record. The nature and

extent of data to be released is outlined below.

The Physician/Health-Related Agency/Provider (as outlined above) will release

The Lee County Schools will release

I understand this information will be used for:

The doctrine of informed consent has been explained to me and I understand the contents to be released, the need for the information, and that there are statutes and regulations protecting the confidentiality of authorized information. I hereby acknowledge that this consent is truly voluntary and is valid until such request is fulfilled. I further acknowledge that I may revoke this consent at any time except to the extent that action based on this consent has been taken. This consent is valid for one (1) year.

Identifying Information of Client:

Sex Race Date of Birth

Student's Name Parent or Legally Appointed Representative Name

or Student's Signature if age 18 Parent or Representative's Signature

Witness Signature Date Signed