ATTACHMENT A SAIS.CONTACT INFORMATION RELEASE OF INFORMATION CONSENT.PDF

Maricopa County
Human Services Department – Education Division
234 N. Central Avenue ATTACHMENT A
Suite 3201 RELEASE OF INFORMATION
Phoenix, AZ 85004
Phone: 602-506-5911 CONSENT FORM
Fax: 602-506-1886
www.maricopa.gov
Student Name: Date of Birth _______
Bruce Liggett
Director Address _______
Alecia Jackson
Assistant Director Home Telephone #: Mobile Telephone #: _______
Student’s Early Head Start/Head Start Site: __________________________________________
Parent/Guardian Name:___________________________________________________________
As Parent/Guardian of student listed above, I consent for Maricopa County Head Start Zero-Five
program to obtain a Student Accountability Information System (SAIS) number for my student from
the School District listed below or by requesting that the Arizona Department of Education SAIS
website assign a SAIS number. SAIS numbers are assigned to children and follow them thru their
elementary school and high school years. The Maricopa County Head Start Zero-Five program will
monitor the student’s academic progress and track the impact the Head Strat program had in the
child’s performance.
I also consent to the release of my name, the name of my child and contact information to the
School District including contact email and phone number.
By completing the Release of Information Consent Form, the Maricopa County Head Start Zero-
Five program will learn which programs improve children’s learning skills and areas that require
improvement.
Your consent will help us improve our programs and strengthen our communities.
Your help is greatly appreciated!
I authorize Maricopa County Head Start Zero-Five program to release my student’s information to
[SCHOOL/DISTRICT] as well as the Arizona Department of Education.
In addition, I authorize [SCHOOL/DISTRICT] to release identifying and academic performance
student information to Maricopa County Head Start Zero-Five program to support program
accountability and quality improvement activities.
[SCHOOL/DISTRICT] and Maricopa County Head Start Zero-Five program employees are
released from liability for the release of information in accordance with this consent.
Signature of parent/guardian
Relationship to Student
Date
Witness