SIMSBURY PUBLIC SCHOOLS

__________________________________________________ _____________________

__________________________________________________ ________________________

SIMSBURY, CT 06070

AUTHORIZATION TO RELEASE / OBTAIN STUDENT RECORDS

TO: Person or Place to

Release To or Obtain From

To The Attention Of

Street Town State Zip

Phone Fax

FROM: SIMSBURY PUBLIC SCHOOLS Telephone: 860-651-3361

ENROLLMENT OFFICE Fax: 860-651-4343

933 HOPMEADOW STREET

SIMSBURY, CT 06070

(For Office Use)

STUDENT NAME: CT SASID #:

DOB: GRADE: YEAR of GRADUATION: PHONE:

CURRENT ADDRESS:

NEW ADDRESS:

Permission is hereby given to the Simsbury Public Schools to



release



obtain the following

information regarding the above named student:



ALL STUDENT RECORDS (Includes those listed below)



PERMANENT ACADEMIC RECORDS

(Student transcript, standardized test data, supplemental data, etc.)



SPECIAL SERVICES RECORDS

(Planning & Placement Team Meetings, Individualized Education Plans, Psychological, Educational,

Social Work, and / or Speech-Language Evaluations, etc.)



HEALTH RECORDS (other than state mandated records for school attendance)



RECORDS FROM AGENCIES / PROFESSIONALS OUTSIDE THE SCHOOL SYSTEM



VERBAL AND / OR WRITTEN COMMUNICATION BETWEEN SCHOOL STAFF AND

OUTSIDE PROFESSIONALS

Is the student presently receiving Special Education? Yes



Has the student received Special Education in the past? Yes



Signature of Parent / Guardian / Student (18 years of age or older) Date

Reason to release / obtain records:



Family moving into / out of Simsbury



Transfer into /out of Open Choice Program



Student transferring to / from private school



Plan appropriate educational program



Student transferring to / from magnet/tech school



Other

PLEASE COMPLETE AND SIGN BELOW IF YOU ARE WITHDRAWING YOUR CHILD FROM SPS:

Please withdraw my child from Simsbury Public Schools as of

Student’s last day of school

Signature of Parent / Guardian Date

Please read the back of this form for information concerning Student Record Regulations

FOR OFFICE USE: Records Sent / Requested on _____________ Staff _______________________

(Date) (Name or Initials)

SSF/10 Rev. 3-2014

STUDENT RECORD INFORMATION

The parent / guardian or adult student has the right to:

1. Inspect or have a representative review all education records which are collected, maintained,

or used by the school. Please contact the school to set up an appointment in advance to

complete this review.

2. Request from school staff an explanation and interpretation of school records.

3. Receive one free copy of the student’s educational records.

4. Receive upon request a list of types and locations of education records collected, maintained

or used by the school district.

5. Request in writing that the school amend information in the education records that the parent

believes to be inaccurate, misleading or in violation of the privacy of the student. If the

school district decides to refuse to amend the information, the parent will be informed in

writing of the refusal and advised of the right to request a hearing to challenge the

information in the education record.

Release of student information or transfer of school records may take place only with the

informed written consent of the parent \ guardian or adult student.

Further information or clarification of parent’s rights and confidentiality of student records may

be obtained by contacting your Building Principal or the Director of Special Services.

SSF/10 Rev. 3-2014