As the parent or legal guardian of _______________________________
I hereby give my express written consent to the above stated student's school, its
teachers and counselors to speak openly with and provide confidential information to the
Pleasantville Learning Center's Director or other staff members.
I hereby release Pleasantville Learning Center, and all other parties herein named, from
any and all legal claims I may have otherwise had. It is my understanding that this
authorization will remain in full effect unless I invalidate this agreement in writing.
______________________
Printed Name
______________________
Date
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