The Westfield Day School

Mother's Information

Father's Information

I, the parent/guardian, hereby authorize the one time periodic release of information about the student named below.

This information is to be used to plan or provide for appropriate education or clinical services. I understand that the information to be released is confidential and protected from disclosure. I also understand that I have the right to cancel my permission to release information at any time.

I understand that this application is an expression of present intent to apply and to consider The Westfield Day School as a possible option to attend. This application does not guarantee admission, nor is it a commitment to attend.

To Applicant: Please complete this section and deliver this form to your current principal or counselor. It is important that the evaluator feel free to provide information that will give us insight into your current performance; therefore, it is important that the waiver be signed. Evaluations become the confidential property of The Westfield Day School, and are not subject to applicant or parental review.

I hereby give my permission for the following requested information to be sent to the director of admissions at The Westfield Day School. I also understand that the information on this form becomes the confidential property of The Westfield Day School in order for the school to assess the applicant's suitability for the programs offered by the school. I, therefore, waive my rights to review this information prior to, and after, direct delivery to The Westfield Day School.

As attested by our signature on this document, we also agree to the following: In the event of any situation (emergency, sickness or accident) involving the student at a time and/or place that it is impractical to call the parent, or for the parent to be present, the parent authorizes The Westfield Day School to act in loco parentis (in place of parent) to provide whatever care, assistance, management, or services the student may require. The parent agrees to pay for any and all expenses incurred in providing for such needs of the student.