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THE QUAKER SCHOOL AT HORSHAM

AUTHORIZATION FOR RELEASE OF INFORMATION

Student First Namerequired

Student Last Namerequired

Date of Birthrequired (mm/dd/yyyy)

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I authorize (name of present or previous schools)

to release the following information to The Quaker School at Horsham

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Transcript, teacher reports, and other documents Psychological testing/evaluation reports Individual education plans Observations or contacts with students, parents, etc.

I authorize The Quaker School to communicate with the following person(s) regarding the above named student. (Please list names and contact information.)

Physicians / Psychologists / Neuropsychologists / Developmental Pediatricians, etc.

Full Name

Relationship to Student

Phone #

Full Name

Relationship to Student

Phone #

Teachers, administrators, guidance counselors of previous schools

Full Name

Relationship to Student

Phone #

Full Name

Relationship to Student

Phone #

Therapists, counselors, tutors

Full Name

Relationship to Student

Phone #

Full Name

Relationship to Student

Phone #

I/we understand that The Quaker School at Horsham will need this information before an enrollment decision can be made.

I hereby release The Quaker School at Horsham and its employees from any or all liability for any claim arising from the use or misuse of these records by unauthorized persons gaining access to them as a result of The Quaker School at Horsham complying with this authorization.

First and Last Namerequired

Today's Date required (mm/dd/yyyy)

Relationship to Studentrequired

THE QUAKER SCHOOL AT HORSHAM

AUTHORIZATION FOR RELEASE OF INFORMATION

The Quaker School at Horsham. *. 250 Meetinghouse Road, Horsham, PA 19044

215-674-2875 / Fax: 215-674-9913