Brigham Young University-Idaho Early Childhood Education/Early Childhood Special Education Hinckley 353 Return Fax 208 496-4103 Authorization for Exchange of Confidential Information give my permission for BYU-Idaho teacher candidates (clo David Allen, Dean Cioward and ils Cranmer) enrolled in the ED 425 ECSE Strategies course to have access to my chile's records andlor gather information to document my child's educational progress. The name of parties authorized to exchange information: Student Organization BYU-Idaho ED 425 ECSE Strategies Course Address Information to be released ® \FSP Q IEP {2 Occupational Therapy (07) evaluation ® OT progress notes Developmental Specialist evaluation § DD services progress notes © Speech & Language (SLP) evaluation SLP progress notes © Physical Therapy (PT) evaluation © PT progress notes © Social history © Other, | understand that the parties named above are permitted to exchange written and verbal information regarding my child. | further understand that | may revoke this authorization in writing at any time. Child's Name Revised 11-21-06