Release of Information to Receive Resources that Support Children with Hearing, Vision, or Hearing and Vision Concerns

Welcome to school age special education services! Students who have hearing, vision, or hearing and vision concerns have unique linguistic, environmental, and cultural needs. This form is very important to make sure that families of children who have these concerns have appropriate information as they transition from pre-school to school age special education services. 

Within the Pennsylvania Department of Education, the Bureau of Special Education (BSE) and the Bureau of Early Intervention Services (BEIS) work together to provide supports and services to children and families of children with these concerns. They support families with a variety of resources as students transition to school age programs. Working with the BSE and BEIS, the Pennsylvania Training and Technical Assistance Network (PaTTAN) provides a full array of resources targeted to improving student results.

The purpose of this form is to establish a continuation of information and support to families with children who have hearing, vision, or hearing and vision concerns from early intervention into the school system. If you are interested in receiving information and resources from PaTTAN that will assist you in supporting your child, (such as IEP development, accommodations, specially designed instruction, etc.), please complete the following information and submit the form to PaTTAN.  PaTTAN will keep all information you provide on this form confidential.

Section 1

My child has a: *

Section 2

As the parent/guardian of a minor child, I voluntarily provide PaTTAN the information in SECTION 1 above. I understand that PaTTAN will keep the information about my child and family in a confidential manner. I understand that:

  1. I am providing my information voluntarily;
  2. I understand the information on this form; and
  3. I have the right to withdraw my consent to PaTTAN maintaining this information at any time.
Signature of Parent/Guardian *
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