Miami-Dade County Public Schools Consent Form For Mutual Exchange Of Information Page 3
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3LEKÒL PIBLIK MIYAMI
FŇM KONSANTMEN POU ECHANJ EMFŇMASYON
(CONSENT FORM FOR MUTUAL EXCHANGE OF INFORMATION)
Dat
Nom elèv
Dat li fèt
ID#
Mwen otorize ke yo fe echanj enfomasyon sou dosye pitit mwen ou dosye pa-m,
____________________________ , ant Lekòl Leta Miami-Dade Konti ak ajns sa yo mete (tout lekòl,
doktè, sikològ, klinik, esetera, ki te an afè avèk pitit ou):
Nom
Adrès
Dosye yo kapab kite moun wè yo, se dosye ki gen rapò ak:
Dosye yo kapab kite moun wè yo, se dosye ki gen rapò ak:
Moun ki resevwa dosye ya p'ap kite okenn lot moun wè yo san yon konsantman siyen.
Mwen sètifye ke se mwen ki paran ou gadyen timoun, non ekri anro,fòm sa a ou swa mwen se yon
elèv ki majè e ke mwen gen otorite ou siyen pèmisyon sa a.
Non
Siyati
Adrès
Sil vou plè, retounen fòm sa bay:
FM-2128H Rev. (11-03)
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