RELEASE OF INFORMATION

OPTIONAL

I, _________________________________, give permission for Education Station and affiliated tutors to contact my child’s teacher for academic purposes only.

Child’s Name_________________________________________

Teacher Name:________________________________________

Phone Number: _______________________________________

Email:_______________________________________________

Please return to:

Education Station

1192 Indian Springs Road

Pine Bush, NY 12566

Signed,

_______________________________ ___________________________

Parent Signature Print Name

_______________________________

Date