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.
Date
_________________________________________
Signature of Parent/Guardian
_________________________________________
Name (Please print)
Adopted: January 24, 2012
Revised: March 27, 2012
Revised: May 12, 2015
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