Permission For Publication Of Identifiable Student Information

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South Bend Community School Corporation
Special Education Services
215 S. St. Joseph St, South Bend, IN 46601
Ph: 574.283.8130 Fax: 574.283.810
Permission for Publication of Identifiable Student information
Student Name: __________________________ SBCSC ID#: ______________ STN#: ____________________
I, ____________________________________________________
Parent or Guardian
of ____________________________________________________
__________________
Name of Student
Date of Birth
do hereby grant:
South Bend Community School Corporation
215 South St. Joseph St.
South Bend, IN 46601
permission to use identifiable information concerning my child (name, picture, disability, program) in
press releases, brochures, video tape, or other publications prepared for the purpose of staff training and
informing the public about special education.
I understand that once received, this permission is valid unless I submit a written request to the Director
of Special Education.
______________________________________________________
Signature Of Parent/Guardian
______________________
Date
A copy of this signed permission must be sent to Special Education Services.
8/18/12
 

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