Parental Permission Form

Indicates required field

* What is your role?

This form should only be filled out by a student or the parent or guardian of a student. Please instruct the student or their parent or guardian to fill out and submit this form.

Note to Student, Parent/Guardian: Your signature on this form gives permission for Georgia Vocational Rehabilitation Agency VR staff to receive education records and information regarding the student named below to determine if he or she is eligible to receive Transition Services from VR. GVRA is a joint state and federally funded program and works in cooperation with Georgia high schools. We look forward to working with you and your student to assist them in developing the skills needed for successful employment.

* Student's First Name

* Student's Last Name

* Student's Grade Year

Student's Expected Graduation Date

* Student's Expected Graduation Date

School's Name

* School's Name

School Contact's Name

School Accommodations Plan

Student's Gender

Male

Female

Prefer Not To Identify

* Student's Date of Birth

* Are you over the age of 18?

Student's Primary Phone

Student's Secondary Phone

Student's Email Address

Student's Address

* Student's County

Student's City

* Student's Zip Code

Notes

* Student's Ethnicity

White

Asian

American Indian or Alaska Native

Pacific Islander or Native Hawaiian

Black or African American

Other…

* Is the Student Hispanic or Latino?

Yes

I give VR permission to help the student plan for the future. This may include help to:

Participate in Job Exploration Activities.
Learn about his or her strengths, abilities, and capabilities for work and adult living.
Learn habits, attitudes, and behaviors for work.
Identify goals for work and adult living.
Learn skills for adult living.
Explore post-secondary training options.
Take part in community work experiences.

I give the above school permission to release and allow electronic access to all records about the student to VR, including but not limited to:

Individual Education Program (IEP).
School cumulative grade records, including standardized test results.
Psychological Evaluations and reports.
School grades and progress reports.
504 Accommodation Plan.
Career exploration information.
Work experience information and records.

GVRA will not re-release the education records it receives from the above named school to any other person, program, or agency without my written consent unless it is required by law. I may end this consent at any time by providing VR a signed and dated statement to that effect. It will end one year from the date the student no longer receives VR services.

* Student's Signature

Please sign above.

* Guardian's Name

Guardian's Email Address

Guardian's Primary Phone

Guardian's Secondary Phone

* I give permission for my student to sign forms related to transition planning, including a possible application for VR services to continue after high school.

Yes

* Guardian's Signature

Please sign above.

Parental Permission Form

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