Permission For Release of Information - Admissions Office

Filling out this form will grant New Way Academy permission to exchange information with the designated parties.

1Demographic Information > 2Authorization and Signature
Student Information

The Student Whose Information You Are Authorizing to Be Released
Student Name Student Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Parent / Guardian Name Parent / Guardian Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Institution Information

The Party Who You Are Authorizing to Release Information (eg, A School or Doctor)
Individual or School Name(s)
Contact Person (If Applicable)
Phone Phone - ### - ### ####
Email
Additional Institution Information (Optional)

A Second Party Who You Are Authorizing to Release Information (eg, Another School or Doctor)
Individual or School Name(s)
Contact Person (If Applicable)
Phone Phone - ### - ### ####
Email
Receiving Institution Information

The Party Who You Are Authorizing to Receive Information
School Name