Miami-Dade County Public Schools Consent Form For Mutual Exchange Of Information
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MIAMI-DADE COUNTY PUBLIC SCHOOLS
CONSENT FORM FOR MUTUAL EXCHANGE OF INFORMATION
Date
Student's Name
Date of Birth
ID#
I hereby authorize the mutual exchange of records pertaining to my child or myself, ___________
_____________________________ , between the MIAMI-DADE COUNTY PUBLIC SCHOOLS and the
following agencies (include all schools, physicians, psychologists, hospitals, clinics, etc., that have had
significant contact with your child):
Name
Address
The specific records to be disclosed pertain to:
The purpose for making these records available is:
The receiving party will not disclose the information to any other party without signed consent.
I certify that I am the parent or legal guardian of the child named above or that I am a student of majority age
and have the authority to sign this release.
Name (print)
Signature
Address
City, State
Zip Code
Please return this form to:
FM-2128E Rev. (11-03)
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