School Permission Form | Holistic

SCHOOL PERMISSION CONSENT FORM

School Name:

Student’s Grade:

Student Name:

Academic Year:

Principal and/or School Counselor Name:

RE: Permission Form for HEALTH APPOINTMENTS DURING SCHOOL HOURS

I, the parent/guardian, do hereby give permission to Holistic Elevation LLC Staff to visit my child during school hours.

In addition, I also grant permission for my child’s academic records, along with his/her social, legal and behavioral information to be provided to Holistic Elevation staff, as he/she helps my child to become a productive student and community member. Holistic Elevation team will work collaboratively with the school, community, parents and other factoring agencies, along with my child to ensure he/she develops to their full capacity.

Feel free to contact me for further information.

Parent/Guardian's Signature:

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Date:

Parent/Guardian's Signature:

Phone Number:

*This consent is valid until client discharge.