Birth to Five Information Release/Request Form

Birth to Five Parent Outreach Banner Logo

Welcome to Tennessee School for the Deaf!

To release or request information, please fill out the form below.

Thank you!

Child's Name:*

Answer required for "Child's Name:"

Date of Birth:*

Answer required for "Date of Birth:"

Age:*

Answer required for "Age:"

Parent/Guardian Name:*

Answer required for "Parent/Guardian Name:"

Email:*

Answer required for "Email:"

Phone Number:*

Answer required for "Phone Number:"

I hereby give my consent for the Tennessee Schools for the Deaf...*

Answer required for "I hereby give my consent for the Tennessee Schools for the Deaf..."

To request information from

To release information to

Name of Institution to request from/release to:*

Answer required for "Name of Institution to request from/release to:"

Today's Date:*

Answer required for "Today's Date:"

The purpose of this request is for the provision of early intervention services.*

Answer required for "The purpose of this request is for the provision of early intervention services."

Yes

The purpose of this request is for the provision of consultation and collaboration with the family and child Team Members.*

Answer required for "The purpose of this request is for the provision of consultation and collaboration with the family and child Team Members."

Yes

If the purpose of this request is for the provision of consultation and collaboration with the family and child Team Members, please select all that apply:

Answer required for "If the purpose of this request is for the provision of consultation and collaboration with the family and child Team Members, please select all that apply:"

Written Observation Report and Recommendations

Visit to the child's program

Communicate face-to-face or by phone

Secure email exchange with Team Members

Participate in program meetings (e.g. planning, IFSP, IEP, Transition, Intake, etc.)

Goal Pages (e.g. planning, IFSP, IEP, Transition, etc.)

Please provide information for all that apply:

Audiologist

Name:

Answer required for "Name:"

Address:

Answer required for "Address:"

Phone Number:

Answer required for "Phone Number:"

Tennessee Early Intervention System (TEIS)

Contact Name:

Answer required for "Contact Name:"

Address:

Answer required for "Address:"

Phone Number:

Answer required for "Phone Number:"

Early Intervention Resource Agency (EIRA)

Contact Information:

Answer required for "Contact Information:"

Address:

Answer required for "Address:"

Phone Number:

Answer required for "Phone Number:"

Local Education Agency

Name of School Attending/District:

Answer required for "Name of School Attending/District:"

Address:

Answer required for "Address:"

Phone Number:

Answer required for "Phone Number:"

Other

Contact Information:

Answer required for "Contact Information:"

Address:

Answer required for "Address:"

Phone Number:

Answer required for "Phone Number:"

Please fix the highlighted areas below before submitting.

Birth to Five Information Release/Request Form