Birth to Five Information Release/Request Form

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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

Date of Birth:*

Answer Required

Age:*

Answer Required

Parent/Guardian Name:*

Answer Required

Email:*

Answer Required

Phone Number:*

Answer Required

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

Answer Required

To request information from

To release information to

Name of Institution to request from/release to:*

Answer Required

Today's Date:*

Answer Required

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

Answer Required

Yes

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

Answer Required

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

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

Address:

Answer Required

Phone Number:

Answer Required

Tennessee Early Intervention System (TEIS)

Contact Name:

Answer Required

Address:

Answer Required

Phone Number:

Answer Required

Early Intervention Resource Agency (EIRA)

Contact Information:

Answer Required

Address:

Answer Required

Phone Number:

Answer Required

Local Education Agency

Name of School Attending/District:

Answer Required

Address:

Answer Required

Phone Number:

Answer Required

Other

Contact Information:

Answer Required

Address:

Answer Required

Phone Number:

Answer Required

Please fix the highlighted areas below before submitting.

Birth to Five Information Release/Request Form