AUTHORIZATION TO EXCHANGE INFORMATION

Your student receives the best educational, skill-building and mentoring experience when faculty, staff, and administrators communicate and collaborate! I authorize The Academy of 21st Century Learning ("Academy") to receive, exchange, and provide information that the Academy believes may be beneficial to the tutoring and instruction of my student

with my student's teachers, counselors, physicians, and others that the Academy deems appropriate for the benefit of my student. I also authorize my student's teachers, counselors, physicians, and others to provide information to The Academy including confidential disclosures that they deem appropriate in their discretion for the tutoring and instruction of my student. I believe that this mutual exchange of information is necessary and appropriate for the purpose of providing the very best educational experience to my student. Please select one of the options below:

YES, I have read the above and grant authorization as stated

NO, I do not grant authorization as stated above

Students *

Students

First Name

Last Name

School Name *

School Phone *

School Phone

(###)

###

####

School Address *

City *

State/ Province *

Zip Code *

School Principle *

Counselor *

Teacher | Subject | Phone | Email *

Parent | Guardian *