CONSENT FOR RELEASE OF RECORDS

I hereby authorize            ________________________________________________

                                                Name of School

________________________________________________________________

Address                                                                                                  City        ,                     State              Zip

to release information concerning: ____________________________________

                                                                                    Name of Student (Full Legal Name)                            Grade

Type of records to be released:

¨  Academic      ¨  Health     ¨  Standardized Testing Scores     ¨  ARD File

¨  Other: _________________________________

Forward records to:                 St. Clement Mary Hofbauer School

                                                            1216 Chesaco Avenue

                                                            Baltimore, MD 21237

My signature below gives consent to the above school to release any records and health information concerning my child.

                                                           ___________________________________                                                                  Parent Name – Please Print                                                                                           ___________________________________

Address        

___________________________________

  City State Zip

___________________________________

           Parent Signature

___________________________________

        Date

CONSENT FOR RELEASE OF RECORDS

I hereby authorize St. Clement Mary Hofbauer School to release information

concerning: ________________________________________        _________

                             Full Legal Name of Student – PLEASE PRINT                                                       Grade

Type of records to be released:

¨  Academic      ¨  Health     ¨  Standardized Testing Scores    

Forward records to:                  ________________________________________

                                                                Name of School

                                                ________________________________________

                                                                Address of School

                                                ________________________________________

                                                                City                                                          State                        Zip

My signature below gives consent to St. Clement Mary Hofbauer School to release any records and health information concerning my child.

                                                           _____________________________________                                                                    Parent Name – Please Print                                                                                               

      ___________________________________

Address                                                                                                       

      ___________________________________

City                                                State                                Zip

                ___________________________________

Parent Signature

     ___________________________________

Date