HARDIN COUNTY
SPECIAL EDUCATION
114 South Mulberry
Elizabethtown, KY
42701
(270) 769-8843
Student: _______________________________________________________________
SSN: __________________________________________________________________
Date of Birth: ___________________________________________________________
Current School: __________________________________________________________
Previous School or Agency: ________________________________________________
Address: _______________________________________________________________
Phone: ______________________________Fax: _________________________________
Permission is hereby granted to the Hardin County Schools to (OBTAIN) (RELEASE) information concerning the child named above.
The following information is requested in order to determine eligibility for specially designed instruction and to develop appropriate educational programming for the above named student:
_____ Cumulative Records _____ Evaluations/Reports
_____ Immunization Certificate _____ IEP
_____ Physical _____ Due Process Records
_____ Birth Certificate _____ Medical History/Diagnostic Records
_____ Other: specify_____________________________________________
Please
send records to:
(Insert School Address) Hardin County Special Education
114 South Mulberry
Elizabethtown, KY 42701
Fax # 270-706-8000
I have the right to act as this student’s representative as I am his/her parent/guardian:
Signed: __________________________________________________
Relationship: ____________________________________________________________
Address: _______________________________________________________________
Phone: _________________________________________________________________
Date of Release: _________________________________________________________
Student’s Signature (if over 18): _____________________________________________
Fax a copy of current IEP to the school listed above. You may send copies of the items requested above to the District Special Education office.
Records have been requested Date: _______________________
Special Ed. Office needs to request records