TFFC Tutoring Consent to Exchange Information Form

Tidewater Friends of Foster Care provides in-home tutoring for youth that are interested in improving their academic performance.

School Consent to Release of Information

Students participating in the TFFC Tutoring Program require a School Consent to Release student records on file with TFFC.

Name of Person Completing Tutoring Information Consent*
First Last
NOTE: The Consent for Information Exchange must be signed by the Parent or Legal Guardian.
Email*
TFFC Tutoring Program
TFFC provides one-on-one tutoring instruction to youth. Enrolled students remain eligible for tutoring through the end of the academic year. Parents/Guardians are responsible for providing a consent to release grades information, a suitable work environment, as well as materials and supplies. Parents/Guardians may request a change of tutor if the relationship is not working for their student.
Student Information
Student's Name*
First Last
Date of Birth*
Month
Day
Year
Student's Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
School*
Grade Level*
CONSENT TO EXCHANGE INFORMATION ON STUDENT
As the Parent/Legal Guardian, I understand that Tidewater Friends of Foster Care, Inc. (TFFC) provides services and benefits to my child. TFFC must have specific information to provide these services and benefits. By signing this form, I am allowing TFFC to exchange certain information so it will be easier for them to provide or coordinate these services or benefits. This consent will be provided to the school to allow exchange of information in support of tutoring services.
Parent/Legal Guardian's Name*
First Last
Legal Guardian's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
I want the following confidential information about the Student to be exchanged with Tidewater Friends of Foster Care, Inc. - 999 Waterside Dr., Suite 103, Norfolk, VA. 23510 Phone: 757-227-4187 Fax: 757-561-0979 Email: tutoring@tidewaterffc.org*
- Select All
- Grades, Progress Reports and Report Cards
- IEPs, 504 plan, DRAs & SOLs
- Verbal & written communication with student's academic team
- Assessment Information
This information will be exchanged ONLY for the purpose of Service Coordination for the TFFC Academic Tutoring Program.
Period of Consent*
I can withdraw this consent at any time by notifying Tidewater Friends of Foster Care. This will stop all Schools/Agencies from sharing information after they know my consent has been withdrawn. I have the right to know what information about has been shared, and why, when, and with whom it was shared. If I ask, Tidewater Friends of Foster Care will show me this information.
Consent*
I agree to the above Exchange of Information.
Electronic Signature*

By selecting CONSENT box and Typing my Full Name above, I confirm my consent and understand that I am electronically signing this form.
Today's Date*
Month
Day
Year
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Name
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TFFC Tutoring Consent to Exchange Information Form

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CONSENT TO EXCHANGE INFORMATION ON STUDENT

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