Release Form

For the 2022-23 School Year: This online form must be completed for all new admissions to The Summit School. Asterisk (*) indicates a required form field. An email-based reference copy of the form information will be sent to the person submitting the form once processed by Summit’s administrative team.

We are asking all new parents/guardians to read and sign Summit’s Release Form for the 2022-23 school year for their child. If no form updates/revisions are made annually, this release form remains in effect while your child attends The Summit School.

Student Name*

First Name

Last Name

Date of Birth*

I authorize The Summit School to do the following:

1. To have my child taken off the school’s premises for field trips with staff supervision. This includes students 14 years old and above who participate in our work-based learning program.

Opt Out (please check only to deny permission)

2. To furnish any information which may come into its possession concerning my child to the NY State Education Department, the referring school district, and/or any government agency that may be contributing to the educational support of my child. The school may determine in its sole discretion to grant or deny any requests for information and the nature and extent of the information to be furnished in compliance with FERPA regulations.

Opt Out (please check only to deny permission)

3. To obtain/share information with my child's healthcare providers in compliance with HIPPA regulations.

Opt Out (please check only to deny permission)

4. To communicate with me via electronic mail. This includes sending information that may be confidential in nature.

Opt Out (please check only to deny permission)

5. To provide and/or obtain emergency care for my child in the event of sudden illness or injury.

Opt Out (please check only to deny permission)

6. To administer and evaluate educational, speech, and occupational therapy assessments of my child as deemed appropriate by educational and clinical staff.

Opt Out (please check only to deny permission)

7. To include parent contact information, including names, addresses, telephones, and emails, as well as student’s name and class in the school’s directory that is distributed only to parents.

Opt Out (please check only to deny permission)

8. To include my child in interviews, photographs, movies, and videos about his/her school-related work. I also grant The Summit School the right to edit, use, and reuse said products for nonprofit purposes. I also hereby release The Summit School and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.

Opt Out (please check only to deny permission)

Acknowledgement*

By selecting this button, I acknowledge that I have read the release requests noted above and that I provide authorization, unless noted otherwise, to The Summit School.

Special Instructions

Parent/Guardian Name*

First Name

Last Name

Parent/Guardian Personal Email:*

Date Submitted*