Ventura — Release of School Information

Ventura — Release of School Information¶

VN133 Superior Court of California County of Ventura Family Court Services

PO BOX 6489 800 SOUTH VICTORIA AVENUE ROOM 307 (805) 289-8735 VENTURA CA 93009 FAX (805) 477-5865

RELEASE OF SCHOOL INFORMATION

I ___________________________________________ , guardian of _______________________________________ Guardian's Name Child's Name

grant permission for __________________________________________________ to release information about the Name of School Official or School

health and well-being of the child under guardianship to the Ventura County Superior Court.

Date Guardian's Signature

Guardian's Printed Name

THE SECTION BELOW WILL BE COMPLETED BY THE SCHOOL REPRESENTATIVE

SCHOOL INFORMATION

Case No.: _______________________

Child's name and age Guardian's name

Address City State Zip

Name of School: ________________________________________________________________________________

Address of School: __________________________________________________ Phone: ____________________

Student's grade level: ____________________________________________ Grade Point Average: ____________

Name of Teacher/Counselor: ______________________________________________________________________

How would you describe the student's attendance record? _______________________________________________

Describe the student's areas of strength and weakness: _________________________________________________

Mandatory Form RELEASE OF SCHOOL INFORMATION Page 1 of 2VN133 (Rev. 07/12)

VN133 SCHOOL INFORMATION

How would you rate the student's general social conduct and adjustment? ___________________________________

Does the student have any special needs? (Please describe) _____________________________________________

If yes, what has the school done to address these needs? _________________________________________

Does the student have any special problems? _________________________________________________________

Is the student receiving additional academic or counseling support? Please describe: __________________________

Does the student appear properly attired and groomed for school? _________________________________________

Do you have any observations or additional comments regarding the caretaker's (parent, grandparent, or relative) history

of responsiveness to the social/academic needs of the child(ren)? _________________________________________

What further follow up would you recommend? ________________________________________________________

Name of person filling out form Title of person filling out form

Signature of person filling out form Date of signature

Please enclose a photocopy of the most recent grades and immunization record

Mandatory Form RELEASE OF SCHOOL INFORMATION Page 2 of 2VN133 (Rev. 07/12)