_____Health/Medical Records _____School Records. _____Speech and Language Reports _____Hearing and Vision Reports. _____
Children’s Transition Network/Madison Transition Team Release of Information/Release of Records Child’s Name (First) _______________________ (Middle) ____________________ (Last) _______________________________ D.O.B. _______________________________________ Residence County____________________________________________ Address _________________________________________ City ________________________________ Zip__________________ Home Phone __________________________Work Phone ___________________________ Other_________________________ Cell Number__________________________ Email Address _______________________________________________________ I hereby authorize the following Interagency Council(s) and other designated persons or agencies to engage in verbal, written, facsimile*, or computerized communication for my child. All pertinent records and information can be released. I am aware that this information will be strictly confidential and will be used in my child’s best interest in order to provide the best medical and educational transition planning. I am aware that my child’s needs may be discussed at a Council meeting and that I may participate as an advocate for my child. I am also aware that my child’s information will be entered into the Children’s Registry and Information System maintained for the State of Florida by the Florida Diagnostic and Learning Resources System. The list of members of the Interagency Council will be provided to me. I am aware that I may deny consent for disclosure to any of the agencies designated. INTERAGENCY COUNCIL AUTHORIZED TO EXCHANGE INFORMATION INCLUDE: Children’s Transition Network Columbia, Hamilton, Lafayette, Madison and Suwannee Counties Children’s Medical Services Department of Health Early Learning Coalition Division of Blind Services
Early Steps FDLRS Florida School for the Deaf and Blind
Information will not be disclosed to any party except personnel with a specific and legitimate educational or medical service interest without prior written consent of parent or legal guardian. THE FOLLOWING RECORDS MAY BE EXCHANGED: please initial _____Screening Results _____Psychological Testing _____Social/Developmental History _____Health/Medical Records _____Speech and Language Reports _____Behavioral Screening Checklists/reports
_____Occupational/Physical Therapy Reports _____Staffing Reports/Family Support Plans/IEP _____School Records _____Hearing and Vision Reports _____Behavioral/Developmental Screening and Evaluation
Name (print) __________________________________________ Relationship _________________
SIGNATURE OF PARENT/GUARDIAN: ____________________________________________DATE: _______________ “The Florida Diagnostic & Learning Resources System is funded by the State of Florida, Department of Education, Division of Public Schools and Community Education, Bureau of Exceptional Education and Student Services, through federal assistance under the Individuals with Disabilities Education Act (IDEA), Part B; IDEA Part B, Preschool; and State General Revenue funds.” Equal Opportunity Schools — Save A Friend Hotline 1-877-7FRIEND
*Following agency procedures for faxing confidential information
