I hereby authorize the exchange of any and all confidential information of a psychological, audiological, speech and language, educational or medical nature concerning my child,

_______________________________________, birthdate __________________between Kyrene School District #28, Student Services Department, 8700 South Kyrene Road, Tempe, Arizona 85284,

and________________________________________________________________to help in determining special learning problems my child may be having. This information will be used only by school officials in a professional manner in the interest of the person named above.

_____________________________ ______________________________
Signature of Parent or Guardian                          Date       

_____________________________
Witness