RELEASE FORM

For the 2018-19 School Year: This form must be completed for all students attending The Summit School.

We are asking all parents/guardians to read and sign Summit’s Release Form for the 2018-19 school year as information in this form has been updated and/or revised since last year. If no form updates/revision are made annually, this release form remains in effect while your child attends The Summit School.

I authorize The Summit School to do the following:

Student Name *
Student Name
1. To have my child taken off the school’s premises for field trips with staff supervision. This includes students 14 years old and above who participate in our work-based learning program.
2. To furnish any information which may come into its possession concerning my child to the NY State Education Department, the referring school district, and/or any government agency that may be contributing to the educational support of my child. The school may determine in its sole discretion to grant or deny any requests for information and the nature and extent of the information to be furnished in compliance with FERPA regulations.
3. To obtain/share information with my child's healthcare providers in compliance with HIPPA regulations.
4. To communicate with me via electronic mail. This includes sending information that may be confidential in nature.
5. To provide and/or obtain emergency care for my child in the event of sudden illness or injury.
6. To administer and evaluate educational, speech, and occupational therapy assessments of my child as deemed appropriate by educational and clinical staff.
7. To include parent contact information, including names, addresses, telephones, and emails, as well as student’s name and class in the school’s directory that is distributed only to parents.
8. To include my child in interviews, photographs, movies, and videos about his/her school-related work. I also grant The Summit School the right to edit, use, and reuse said products for nonprofit purposes. I also hereby release The Summit School and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.
Acknowledgement *
Please include any special instructions and/or comments in the text box below.
Parent/Guardian Name *
Parent/Guardian Name
Date Submitted *
Date Submitted