School-to-Agency Student Data Sharing Form
Student Information
Student Name
Date of Birth
Grade
Student ID Number
Parent/Guardian Information
Parent/Guardian Name
Phone or Email
Agency Information
Agency Name
Agency Contact Person
Agency Contact Email
Data to be Shared
Attendance
Grades
IEP/504 Plans
Discipline Records
Other
If Other, specify
Purpose of Data Sharing
Consent and Authorization
Name of Parent/Guardian Giving Consent
Date
I authorize the school to share the above information with the named agency for the purposes stated.