Teen REACH Release of Information (pdf)
Fields from the form shown below:
(Your agency logo here)
Teen REACH Parental Consent Form
General Information
Name:
Address:
City:
State:
Zip Code:
- Date of Birth:
- Age:
- SSN(optional):
- Grade:
School Name:
- Address:
- Phone:
- Teacher:
- Room Number:
Release of Information:
As the legal parent/guardian of FIELD, I authorize the School District and/or the educational institute my child attends to release the following information to this Teen REACH site on a
quarterly basis: grade point average, photocopies of report cards, school attendance rates, grade achievement information and graduation information.
Parent/Guardian Signature Date
Home Phone Number:
Work Number:
