Release Of School Information {VN133}

Superior Court of California County of Ventura Family Court Services PO BOX 6489 800 SOUTH VICTORIA AVENUE ROOM 307 VENTURA CA 93009 VN133 (805) 289-8735 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 VN133 (Rev. 07/12) RELEASE OF SCHOOL INFORMATION Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com SCHOOL INFORMATION VN133 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 VN133 (Rev. 07/12) RELEASE OF SCHOOL INFORMATION Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com