School Release of Information 2022

Student's Name  

Guardian's Name  


Authorization for Exchange of Confidential Information with Lewiston Independent School District No. 1 and Clarkston School District.

(This form allows information about your student to be exchanged.)
I authorize Michelle King, President, LC Valley Youth Resource Center at 1633 10th Avenue, Lewiston, ID 83501 to obtain information from Lewiston High School, Clarkston High School, Jenifer Junior High School, Lincoln Middle School, Sacajawea Junior High School, Lewiston School District, and Clarkston School District.

By signing this authorization, I understand that the parties named above are permitted to exchange written and verbal information regarding my child with Lewiston and/or Clarkston School District. This includes official school records, transcripts, teacher/counselor/staff observations, social work reports, and counseling records.

This authorization is for the purpose of providing information for the care of my child at the LC Valley Youth Resource Center.

The parties also accept a photocopy of this release form and give it the same full force and effect as the original. I further understand that I may revoke this authorization in writing at any time by providing a copy of my revocation to the parties named above. The information used or disclosed under this release might be disclosed by the school district as an education record pursuant to FERPA and might no longer be protected by HIPAA.

I give CONSENT for the bidirectional exchange of information.

Liability Release 
I hereby release, indemnify and hold harmless LC Valley Youth Resource Center, its officers, directors and employees, and the organizers, sponsors and supervisors of all LC Valley Youth Resource Center activities from any and all liability in connection with any injury my child may sustain (including any injury caused by negligence) at the LC Valley Youth Resource Center.

Consent to Video Surveillance
I understand the LC Valley Youth Resource Center utilizes a 24-hour video monitoring system in all rooms, excluding restrooms. I hereby grant and authorize the LC Valley Youth Resource Center Inc to record video of the student listed on this form while on the premises at 1633 10th Avenue, Lewiston, Idaho.

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Signature Certificate
Document name: School Release of Information 2022
lock iconUnique Document ID: 87b2d3a556e4fa508a9c300f6a8e78c4b1115f9f
Timestamp Audit
February 11, 2022 3:44 pm PDTSchool Release of Information 2022 Uploaded by Michelle King - IP