Arkansas City Public Schools 2545 Greenway, Arkansas City, KS 67005 Phone: 620-441-2000 www.usd470.com
RELEASE OF CONFIDENTIAL INFORMATION Date: ___________________
To: ________________________________ ________________________________ ________________________________ The Student(s) listed below recently enrolled in our district. Please send all educational, Special services, psychological, immunization, and health records to the school indicated below: Does this child have or ever had an ever had an IEP? Name
Grade
Yes
No
Name
Grade
Yes
No
Name
Grade
Yes
No
Name
Grade
Yes
No
Parent Signature
Send records to school indicated: _____ Adams Elementary, 1201 North 10th, Arkansas City, KS 67005, Fax 620-441-2044 _____ C-4 Elementary, 11945 292nd Road, Arkansas City, KS 67005, Fax 620-441-2049 _____ Frances Willard Elementary, 201 North 4th, Arkansas City, KS 67005, Fax 620-441-2054 _____ IXL Elementary, 6758 322nd Road, Arkansas City, KS 67005, Fax 620-441-2059 _____ Jefferson Elementary, 131 Osage, Arkansas City, KS 67005, Fax 620-441-2064 _____ Roosevelt Elementary, 300 North B Street, Arkansas City, KS 67005, Fax 620-441-2074
Arkansas City Public Schools 2545 Greenway, Arkansas City, KS 67005 Phone: 620-441-2000 www.usd470.com
AUTORIZACIÓN PARA LIBERAR INFORMACIÓN CONFIDENCIAL Fecha: ___________________
Para: ________________________________ ________________________________ ________________________________ Los estudiante(s) nombrado(s) a continuación se inscribieron en nuestro distrito escolar recientemente. Por favor envíe todos los registros educativos, servicios de educación especial, psicológicos, vacunas y registros de salud a la escuela que se indica a continuación: ¿Este niño tiene o ha tenido un IEP? Nombre
Grado
Sí
No
Nombre
Grado
Sí
No
Nombre
Grado
Sí
No
Nombre
Grado
Sí
No
Firma del Padre
Envíe los registros a la escuela indicada: _____ Adams Elementary, 1201 North 10th, Arkansas City, KS 67005, Fax 620-441-2044 _____ C-4 Elementary, 11945 292nd Road, Arkansas City, KS 67005, Fax 620-441-2049 _____ Frances Willard Elementary, 201 North 4th, Arkansas City, KS 67005, Fax 620-441-2054 _____ IXL Elementary, 6758 322nd Road, Arkansas City, KS 67005, Fax 620-441-2059 _____ Jefferson Elementary, 131 Osage, Arkansas City, KS 67005, Fax 620-441-2064 _____ Roosevelt Elementary, 300 North B Street, Arkansas City, KS 67005, Fax 620-441-2074
