Educational Release | Missy Bee Advocacy Services

Educational Records Release &

Advocacy Representation Authorization

Parent/Guardian Information

Child Information

First name

Last name

Name

Email

Date of Birth

Phone

Student ID

School District Information

District Name

School Name

Phone Number

Email

Records Authorized for Release

Parent to check all that apply

IEPs & 504 Plans

MTSS/RTI documentation

Eligibility reports & meeting notes

Grades, attendance, discipline records

Behavior plans & intervention data

Any records relevant to special education decision making

Evaluations (psychoeducational, speech, OT, PT, behavioral)

Electronic communications, internal/external emails, and staff correspondence regarding my child

Representation Authorization

I authorize my advocate to:

Speak on my behalf in meetings

Request clarification or documentation

Participate in IEP/504/eligibility meetings

Communicate with teachers, administrators, and service providers

Submit written parent concerns

Assist in drafting or reviewing IEP/504 documents

Receive digital or physical copies of all student records and correspondence directly

Note: This does not transfer decision‑making rights. I retain full parental authority.

Advocate Information

Advocate Name: Melissa Langford
Business Name: Missy Bee Advocacy Services, Inc.
Phone: (943) 285-2199
Email: melissa@missybeeadvocacy.com

Legal Consent & Expiration

Pursuant to the Family Educational Rights and Privacy Act (FERPA) (34 CFR Summary Part 99) and the Individuals with Disabilities Education Act (IDEA), I hereby authorize the school district listed above to disclose and release the selected student records and personally identifiable information (PII) to Melissa Langford / Missy Bee Advocacy Services, Inc.

This authorization is valid for one year from the date of signing unless revoked by me in writing.

Signature

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Date