DeafBlind Program / Outreach Services Two-Way Authorization for Release of Records

Complete this form to authorize release of medical and/or educational records between: WSSB/WA DeafBlind Project and the agencies/providers.

Instructions:

This form is designed to be completed by 2 participants.

Participant 1: School District/Agency Staff or Provider

  • Enter known information in appropriate fields
  • Please complete school district/agency info. on pg. 2
  • Follow steps provided to send to Participant 2: Parent/Guardian

Participant 2: Parent/Guardian

  • Complete and update any fields as needed
  • Initial and sign as indicated

A signed copy will be sent to all participants and the WA DeafBlind Program.

Likes and Dislikes Form

Complete this form about the student’s likes and dislikes.

Note: Download the fillable PDF form to your computer or device to be able to save your data.