Release of Confidential Information

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Student Name*
First Middle Last
Release of Confidential Information
It is requested that any professional information you have regarding:*
Applicant's Name
First Middle Last
be released to Greg Mathis Charter High School. This includes any psychological reports, Individual Education Plans, medical reports, psychiatric evaluations, psychiatric hospital records, school transcripts, DJJ Evaluations, legal status documentation, and other pertinent information that schools, counselors, or doctors may have.
Birth Date*
MM
DD
YYYY
Social Security Number*
Applicant's Signature*
Date*
Date Format: MM slash DD slash YYYY
Parent/Guardian's Signature*
Date*
Date Format: MM slash DD slash YYYY
Please mail or fax this information to: 2872 Azalea Drive North Charleston, SC 29405 Fax: 843 746-8568
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