Disclosure Form- Jodi

This disclosure document serves as consent for exchange of information regarding a student with whom I am working. This authorization shall remain in effect until the termination of services by either Jodi Walder-Biesanz or the person who has signed below. A photocopy or facsimile of this authorization shall be as valid as the original. I welcome an exchange of information regarding any college planning and academic issues and in general an open, collegial relationship that would benefit the student. If you have any questions, please feel free to contact me via phone, e-mail or fax. I look forward to working with you.

Jodi Walder-Biesanz

Student Full Name *

First Name Middle Name Last Name

Date of Birth *

Month Day Year

School *

Graduation Year *

School Counselor *

First Name Last Name

School Counselor Email *

School Counselor Phone Number *

Area Code Phone Number

School District *

Test Prep Provider

First Name Last Name

Test Prep Provider email

Test Prep Provider phone

Area Code Phone Number

I hereby authorize the exchange of information regarding the above named student between Jodi Walder-Biesanz, College Admissions Coach and Minds Matter College Counselor and the staff of the above mentioned school district and/or educational professional for the purpose of educational coordination.

Student Signature *

Clear

Parent/Guardian Signature *

Clear

Relationship to Student *

Consent for Exchange of Information