FORM E
ENFIELD PUBLIC SCHOOLS
Report of Teen Dating Violence/Consent to Release Student Information
Date:
Name of Student:
________________________________
________________________________
School:
________________________________
To Parent/Guardian:
A report of teen dating violence has been made on behalf of your child alleging that he/she has
been the victim of teen dating violence. In order to facilitate a prompt and thorough review of the report,
the [__________________] Public Schools may wish to disclose the fact that this complaint has been
filed in connection with its review.
(Please check one):
_______ I hereby give permission for the Enfield Public Schools to disclose the fact that a
complaint concerning my child has been filed as part of its review of that complaint.
______ I do NOT give permission for the Enfield Public Schools to disclose the fact that a
complaint concerning my child has been filed as part of its review of that complaint.
____________________________________________________
Signature of Parent/Guardian
Date
_________________________________________
Name (Please print)
Adopted: January 24, 2012
Revised: March 27, 2012
Revised: May 12, 2015
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