SOUTH HUNTINGTON UFSD

OFFICE OF STUDENT SERVICES

60 Weston Street
Huntington Station, NY 11746
(631)812-3155
Fax (631)812-3165

RELEASE OF INFORMATION

STUDENT INFORMATION:

First Name: *

Last Name: *

Date of Birth: * +

Permission is hereby granted for communication and, if needed, to release a copy of my child’s records (Demographic, Educational, Psychological, Psychiatric, Medical, Social History, Speech and Language, Occupational Therapy, Physical Therapy, Neurological, Individual Education Plan, 504 Plan), or other (listed below)

Other: * 🛈

to be released between:

School or Name, Address, Phone Number of Person/Practice: *

And

South Huntington Union Free School District and its designees
Office of Student Services
60 Weston Street,
Huntington Station, NY 11746

PARENT/GUARDIAN INFORMATION:

First and Last Name: *

Today's Date:

Receive a copy of this via email? *

Email Address:

Parent/Guardian's Signature: *

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