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Beaufort Jasper EOC Head Start

Consent to Release of Information

Parental Consent to Release and Receive Information

Child's Last Name:*
Child's Middle Name:
Child's First Name:*
Parent Name: *
What program option are you registering for?*



give permission to release or receive all personally identifiable information indicated below in reference to my child, born to the organizations and/or individuals listed below.

This consent gives Beaufort-Jasper EOC Head Start permission to release the following records regarding my child to the Beaufort and/ or Jasper County School District, and, gives permission to the Beaufort and/ or Jasper County School District to release the following records regarding my child through the third grade to Beaufort-Jasper EOC Head Start

Release or Receipt of information between
Baby Net (Children birth to 3 years old)
Department of Social Services
Early Interventionist
Pediatrician and other physician(s)
Release or Receipt of information between
Educational and/or Developmental Screenings Results
Educational Assessment Scores
Hearing/Vision Screenings and/or Results
Medical Records
Evaluation Results
Certificate of Immunization
Copy of Birth Certificate

The information being released or received will assist the organizations listed in gathering information for school enrollment and/or transition, record keeping, and data collection purposes for continuous program improvement.

I understand that I have the right to INSPECT, COPY, and CHALLENGE the content of the records for which I am authorizing release. I understand this consent may be revoked in writing by me at anytime, except to the extent that the information has already been used. I understand that until this revocation is made, this consent shall remain in effect and the records will continue to be provided for the specific purpose described above.

I confirm that I have read and understand this form. *

Parent Signature