SUDBURY CATHOLIC DISTRICT SCHOOL BOARD
165A D’YOUVILLE  STREET, SUDBURY, ONTARIO  P3C 5E7  tel. (705) 673-5620   fax (705) 673-6670 http://www.scdsb.edu.on.ca

SE 11A(IEP)
OSR FILE
2007 04 23
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PARENTAL AUTHORIZATION 
TO RELEASE INFORMATION

SCHOOL				School Year		
											
To further assist School and/or Board Special Education personnel identify the needs of	
___________________________
Full Name of Student	_____________________
Date of Birth	______________
Student Id. # (OEN)	

the undersigned parent(s) or guardian(s) hereby authorize(s) the Sudbury Catholic District School Board, Special Education Student Services Department to:

☒	  release information from the student’s most recent IEP (Individual Educational Plan): strengths, needs, accommodations, learning expectations, teaching strategies and assessment methods

to:         The Learning Disabilities Association of Sudbury 2014-2015 
              Coaching Program Coordinator and Coach

for:         the sole purposes of The Learning Disabilities Association of Sudbury 
              Coaching Program in partnership with the Laurentian University
              School of Education

_______________________
   date
	__________________________
signature of Parent(s) or Guardian(s)	

Note:	In accordance with the Municipal Freedom of Information and Protection of Privacy Act, the information provided on this form will be used solely for recording purposes and for use in the O.S.R.  Please direct any inquiries to the Board's Freedom of Information Coordinator at 673-5620.