Phone (931) 232-5505 Fax (931) 232-8139

I hereby authorize ____________________________________ School to release all records concerning _________________________________ to the Stewart County School System.

This will include all that apply:

____ Cumulative Records

___ Psychological Reports

___ Psycho-educational Reports

___LD Team Reports

___ IEP’s

___ Speech & Hearing Evaluations

___ Other: ______________________________

__________________________________

Parent/Guardian Signature

_________________________________

Date

Send to:

North Stewart Elementary School Records

2201 Hwy. 79

Big Rock, TN 37023

Please forward to your Special Education Department.