Information Release Consent Release of Information Form Name(Required) First Last Student's Name(Required) First Last Email(Required) Enter Email Confirm Email I authorize staff from the Centre for Literacy to share information about my child with the following: Teacher, principal, learning coach, or other employee of the school my child attends Consultants or other officials employed or under contract by my child’s school district Health care providers including physicians, psychologists, counsellors, therapists, or other members of a health discipline The purpose of such communication is one or any of the following: to enhance the overall quality of programming provided at the Centre and/or at the child’s school to collaborate to ensure consistency in approach and goals to maximize the quality of health services that may be needed. Notwithstanding the notice above, the Centre for Literacy is prohibited from sharing information to/with the following: I understand that this authorization may be rescinded or amended at any time by written, dated communication. I understand that my authorization will remain effective from the date of my submission until such time as my child 1) ceases to receive support at the Centre for Literacy, 2) the authorization is replaced, or 3) the authorization is rescinded. Information will be handled confidentially in compliance with all applicable federal laws. I have read and understand the nature of this release.