[Date]

Via Facsimile

Children’s Hospital

200 Henry Clay Ave

New Orleans, LA 70118

                                                                                                                                                                                                                                      [DATE]

VIA EMAIL ONLY

[Name of School Administrator]

[Title]

[Email Address]

                                                                                                                                                                                                                                      [DATE]

VIA EMAIL ONLY

[Name of School Administrator]

[Title]

[School]

                                                                                                                                                                                                                                      [DATE]

VIA EMAIL ONLY

[Name of School Administrator]

[Title]

[School]

I, _____________________________, parent/guardian of_______________________________, hereby authorize ___________________________________________________ to release to the [NAME OF ATTORNEY OR ORGANIZATION] all education records or documents of any kind in its possession related to the student listed below, for whom I am the educational rights holder. This authorization extends to [NAMES OF ALL INDIVIDUALS WHO MAY SUBMIT REQUEST OR RETRIEVE RECORDS].

Basic Info

Parent’s Name:

Phone Number:

Email:

Home Address:

Best time/way to contact parent:

Scope of Representation for IEP Advocacy: